Objective:

To describe therapeutic management in a 38-year-old female with CNS tuberculomas and Immune Reconstitution Inflammation Syndrome (IRIS) compared to literature review.  

Background:

IRIS is a paradoxical worsening or unmasking of infection and inflammation following treatment that promotes rapid immunologic recovery. IRIS is often described with antiretroviral therapy (ART) in HIV, but can also present during tuberculosis (TB) treatment with RIPE. There is no consensus on management of TB IRIS in the context of HIV. 

Design/Methods:

Magnetic resonance image (MRI) with regular medication levels.

Results:

The patient is a 38-year-old female newly diagnosed with HIV-AIDS and disseminated pulmonary/ CNS TB after hospitalization for severe headaches and new-onset seizure. Exam was relevant for pronator drift, and initial MRI revealed masses with moderate edema in bilateral cerebral and left cerebellar hemisphere concerning for tuberculomas. Opportunistic infections (OI) and AIDS-defining illnesses were ruled out (e.g. toxoplasmosis, CNS lymphoma). RIPE therapy with dexamethasone were started with ART initiated two weeks later. Despite appropriate drug levels and RIPE titration, severe mass effect on fourth ventricle warranted surgical resection of cerebellar tuberculoma. Multiple four-week steroid tapers were attempted (prednisone, dexamethasone), but the patient experienced paradoxical growth of tuberculomas, significant rebound edema, and breakthrough seizures Medical team recommended a prolonged steroid course instead, but monthly MRI showed midline shift, uncal herniation and worsening tuberculomas requiring repeat resection. After multidisciplinary discussions, the patient started infliximab infusions that resulted in remarkable IRIS improvement – evidenced both clinically and on MRI.  

Conclusions:

Corticosteroids remain the mainstay of IRIS treatment, though no formal guidelines exist for selecting patients who may benefit from TNF-α inhibitors and adjuvant surgery. This case illustrates infliximab as a lifesaving therapy in refractory IRIS. It also emphasizes the need to consider HIV-IRIS, superimposed infections, medication adherence, drug levels/interactions/pharmacodynamics, and resistant TB strains as part of a multifactorial approach to treatment management