SHM Converge Scientific Abstract ePoster Gallery-Tuberculosis Immune Reconstitution Inflammatory Syndrome: Unusual Tb Unmasking Following Art

Pdf Summary

This case describes a 28-year-old man with untreated HIV who presented with 3 weeks of fatigue, headache, fevers, chills, and night sweats shortly after starting antiretroviral therapy (ART). He had immigrated from Guatemala and was recently started on dolutegravir and lamivudine, along with TMP-SMX and fluconazole prophylaxis. On admission, he was febrile and tachycardic, with a CD4 count of 110 cells/mm³ and detectable HIV viral load.<br /><br />Imaging initially showed a large left paramediastinal mass with extensive supraclavicular and mediastinal lymphadenopathy. Bronchoscopy with bronchoalveolar lavage and lymph node biopsy revealed acid-fast bacilli, supporting tuberculosis (TB) without evidence of malignancy. Clinicians suspected unmasked TB-immune reconstitution inflammatory syndrome (TB-IRIS), where ART restores immune function and triggers an exaggerated inflammatory response against previously subclinical TB. ART was stopped, and RIPE therapy was started.<br /><br />By day 5, the patient developed innumerable pulmonary nodules consistent with miliary TB, illustrating rapid paradoxical worsening after immune reconstitution. His course was complicated by significant transaminitis, requiring temporary discontinuation of RIPE therapy followed by gradual reintroduction.<br /><br />The report emphasizes that TB is a major cause of illness and death in patients with HIV, and TB-IRIS is an important early complication after ART initiation. Clinicians should maintain a high index of suspicion for TB-IRIS in high-risk patients, especially those with advanced HIV or epidemiologic exposure, because ART can unmask occult TB and cause severe inflammatory progression. Close monitoring after ART initiation is essential to recognize unexpected disease presentations and manage complications promptly.

Asset Subtitle

Samah H. Syed

Meta Tag

Author List Folasade Arinze, Kirtan Amin, Rachel Check, Samah H. Syed, Takele Demesilassie

Category Clinical Vignettes

Concept Cryptococcal Meningitis-Associated Immune Reconstitution Inflammatory Syndrome

Concept HIV Therapy

Concept Tuberculosis

Concept HIV

Concept Unmasking

Distinguished Non-Finalist

Presenter Organization Wellstar Kennestone Internal Medicine Residency

Presenting Author Samah H. Syed

Track Adult

Keywords

HIV

tuberculosis

TB-IRIS

antiretroviral therapy

immune reconstitution

miliary TB

acid-fast bacilli

lymphadenopathy

RIPE therapy

transaminitis

Cryptococcal Meningitis-Associated Immune Reconstitution Inflammatory Syndrome

HIV Therapy

Tuberculosis

HIV

Unmasking