# Grave’s disease as a manifestation of immune reconstitution inflammatory syndrome in an HIV-infected child on highly active antiretroviral therapy: A case report

## TL;DR

A rare case of Graves' disease in an HIV-infected child occurred after immune recovery from antiretroviral therapy, highlighting the need for awareness of autoimmune conditions in such patients.

## Contribution

This paper reports a rare pediatric case of Graves' disease as a late manifestation of immune reconstitution inflammatory syndrome following HIV treatment.

## Key findings

- Graves' disease emerged 33 months after ART initiation with significant immune recovery.
- Effective management was achieved using carbimazole and propranolol while continuing ART.
- The case highlights the importance of considering autoimmune thyroid disease in HIV-positive children.

## Abstract

Immune reconstitution inflammatory syndrome (IRIS) can unmask autoimmune disease after antiretroviral therapy (ART), and Graves’ disease has been reported as a late autoimmune manifestation, though pediatric cases are exceptionally rare.

A 9-year-old Ethiopian boy with vertically acquired HIV, diagnosed at age 6 during an acute illness, had presented at that time with profound immunosuppression (CD4 23 cells/mm³, HIV RNA ∼150,000 copies/mL) and was started on combination ART. He achieved sustained virologic suppression and marked immune recovery (CD4 >1800 cells/mm³). Thirty-three months after ART initiation he developed a six-month history of weight loss, palpitations, increased appetite, night sweats and progressive bilateral proptosis. Examination showed tachycardia, lid retraction, lid lag and a diffusely enlarged, soft, non-tender goitre. Laboratory testing revealed suppressed TSH and elevated free T4; thyroid ultrasound demonstrated a diffusely enlarged, hypervascular gland. Thyroid autoantibodies were not available. A clinical diagnosis of Graves’ disease in the context of IRIS was made.

ART was continued. He was treated with carbimazole and propranolol with close endocrine and infectious-disease follow-up. Symptoms resolved, heart rate normalized and thyroid function tests returned to the euthyroid range, allowing down-titration of carbimazole to a maintenance dose.

This case illustrates that Graves’ hyperthyroidism may present as a late IRIS manifestation in children with profound immune recovery after ART. Early recognition, standard antithyroid therapy and continuation of ART can achieve good outcomes.

•Rare pediatric Graves’ disease emerged as IRIS post-ART in HIV.•Onset occurred 33 months after ART with marked CD4 immune recovery.•Diagnosis based on thyrotoxicosis, diffuse goiter, and ophthalmopathy.•Effective management with carbimazole and propranolol, ART continued.•Case underscores need to suspect autoimmune thyroid disease in HIV kids.

Rare pediatric Graves’ disease emerged as IRIS post-ART in HIV.

Onset occurred 33 months after ART with marked CD4 immune recovery.

Diagnosis based on thyrotoxicosis, diffuse goiter, and ophthalmopathy.

Effective management with carbimazole and propranolol, ART continued.

Case underscores need to suspect autoimmune thyroid disease in HIV kids.