UNMASKING OF TUBERCULOSIS BY IRIS: A PLAY OF IMMUNITY

Abstract

TYPE: Case Report Publication TOPIC: Chest Infections INTRODUCTION: Immune Reconstitution Inflammatory Syndrome (IRIS) is an important complication to be expected during anti-Retroviral therapy, caused by rapid restoration of immune response to various pathogens. Tuberculosis is the most common. It can be Paradoxical or Unmasking. Only a few cases of ‘Unmasking-tuberculosis IRIS’ have been described. CASE PRESENTATION: A 43 year old female, known case of PLHA with CD4 count 76cells/ul and HIV-RNA 153808copies/ml was screened for active tuberculosis. Her chest X-Ray was normal, sputum CBNAAT and Tuberculin skin test negative. She was initiated on anti-Retroviral therapy (ART).4weeks later, she came with complaints of cough, fever, breathlessness for 7days.Chest X-Ray and CT chest showed left upper lobe consolidation, multiple mediastinal lymph node enlargement, bilateral pleural effusion and moderate pericardial effusion.She was suspected to be a case of IRIS.She was admitted, started on corticosteroids and ART continued.She showed clinical improvement .After 2weeks,repeat CD4 count increased to 158cells/ul and HIV-RNA decreased to 208copies/ml.Repeat chest X-Ray and ECHO showed resolution. She was clinically diagnosed as a case of Unmasking tuberculosis IRIS and started on anti tuberculosis treatment and ART continued without interruption. DISCUSSION: IRIS is a spectrum of clinucal signs and symptoms resulting from body's ability to mount an inflammatory response associated with immune recovery. It typically occurs within 2-12weeks of ART initiation. Temporal association with initiation of ART, atypical presentation of opportunistic infection and demonstration of immune recovery give clue to diagnosis. CONCLUSIONS: IRIS should be suspected in patients with worsening of disease in the initial few weeks of ART,especially in severely immunocompromised,before misjudging as ART failure. DISCLOSURE: No significant relationships. KEYWORDS: tuberculosis, IRIS, Anti retroviral therapy