# Paradoxical Immune Reconstitution Inflammatory Syndrome Presenting as Extrapulmonary Tuberculosis in a Patient With HIV

## TL;DR

A patient with HIV and a history of tuberculosis experienced a severe immune reaction after restarting HIV treatment, which was diagnosed as paradoxical IRIS.

## Contribution

This case highlights the clinical presentation of paradoxical TB-IRIS as extrapulmonary tuberculosis in an HIV-positive patient.

## Key findings

- The patient developed cervical lymphadenitis three weeks after restarting HAART, consistent with paradoxical TB-IRIS.
- The diagnosis was based on the patient's HIV/TB co-infection history, low CD4+ count, and timing of symptoms.
- The case underscores the importance of considering IRIS in HIV/TB co-infected patients during immune recovery.

## Abstract

Immune reconstitution inflammatory syndrome (IRIS) is an uncoordinated hyperinflammatory response to latent or de novo active infection in immunocompromised individuals following immune recovery. More specifically, paradoxical IRIS refers to the deterioration of a pre-existing infection, whereas unmasking IRIS can be thought of as the unveiling of a previously undiagnosed infection as immune function reconstitutes. HIV-positive patients with advanced disease who are also coinfected with tuberculosis have a uniquely high risk for this complication once started on highly active antiretroviral therapy (HAART).

We present a case of a 58-year-old HIV and tuberculosis (TB)-positive woman from Northern Tanzania who presented to a rural care and treatment clinic (CTC) after a 17-month lapse from HAART. She had previously undergone curative treatment for tuberculosis three years prior, which was also the time of her initial HIV diagnosis and initiation of HAART. She arrived in the clinic cachectic, unwell, and with complaint of malaise and diarrhea. Blood analysis confirmed advanced HIV disease (AHD), and consequently, she was immediately restarted on HAART. Almost three weeks later, she returned to the clinic febrile, severely fatigued, and with grossly evident cervical lymphadenitis. Given her coinfection (HIV and TB positive) history, depleted CD4+ count, new onset of clinical findings, and temporal relationship of symptom appearance from HAART reinitiation, a diagnosis of paradoxical TB-IRIS presenting as TB lymphadenitis was made.