Brainstem tuberculoma: A delayed IRIS

We describe a twenty six years old lady with tuberculous meningitis who developed new onset left ptosis and binocular diplopia with features of left fascicular 3rd nerve palsy after 9 months of anti tubercular therapy (ATT) and imaging revealed new onset tuberculoma in the mid-brain. Tuberculoma responded to steroids while continuing ATT. Formation of new tuberculoma as a part of immune reconstitution inflammatory syndrome (IRIS) is possible even after prolonged therapy of 9 months, which responded well to only steroids without altering ATT.

Cryptococcal meningitis in an immunocompetent patient

Cryptococcal meningitis is a fungal infection that is most commonly thought of as an opportunistic infection affecting immunocompromised patients, classically patients with Human Immunodeficiency (HIV) infection. It is associated with a variety of complications including disseminated disease as well as neurologic complications including intracranial hypertension, cerebral infarcts, vision loss and other neurologic deficits. It is diagnosed by lumbar puncture with CSF studies, including fungal culture and cryptococcal antigen testing. We present a case of cryptococcal meningitis and fungemia in a previously healthy male patient who presented after multiple emergency department visits with persistent headache. After multiple visits, he underwent a lumbar puncture consistent with cryptococcal infection, and he was admitted to the hospital for initiation of antifungal therapy. His workup revealed no known underlying condition leading to immune compromise.

Paradoxical worsening of chest radiographs secondary to immune reconstitution syndrome (IRIS) in a patient with advanced HIV infection and Rhodococcus pneumonia

We present a rare case of post-antiretroviral therapy (ART) paradoxically worsening of radiological findings in a patient with advanced HIV-infection on treatment for Rhodococcus pneumonia who was misdiagnosed with pulmonary tuberculosis. Despite clinical improvement, serial chest radiographs showed deteriorations a month after starting ART. This was attributed to Immune Reconstitution Inflammatory Syndrome (IRIS) which spontaneously resolved without any treatment.

Immune reconstitution inflammatory syndrome in non-HIV patients with tuberculosis. A case series

Tuberculosis associated Immune reconstitution inflammatory syndrome (IRIS) in a HIV negative patient can present with a multitude of clinic-radiological presentations that are often confused with drug resistance/treatment failure. Being a diagnosis of exclusion, this clinical entity is often prone to under-diagnosis. We present a series of 5 patients who presented with varied but uncommon IRIS manifestations. High index of suspicion coupled with clinical reasoning and judicious use of phenotypic and genotypic culture methods helped in their timely detection and successful treatment.

AIDS associated tuberculosis: a catastrophic collision to evade the host immune system

Human immunodeficiency virus (HIV) is a causative agent of AIDS while Mycobacterium tuberculosis causes human tuberculosis, independently. HIV and M. tuberculosis co-infection is an intriguing immunopathological phenomenon. The effect is not simply an additive but far more than that. This review gives an account of how various host and pathogen specific factors interplay to make this co-infection one of the worst co-infection, rightly named as medical "double jeopardy". We have attempted to recount some of the immune mechanisms how both these pathogens disturb the balance of host immune system resulting into defects in the host phagocytic response, leading to apoptosis and chemokine dysregulation. The HIV provides protected shelter to the M. tuberculosis and M. tuberculosis provides conducive atmosphere through the interplay of various chemokines. We also touch upon the treatment associated complications like Immune reconstitution inflammatory syndrome (IRIS) these patients face.

Recognition of immune reconstitution syndrome necessary for better management of patients with severe drug eruptions and those under immunosuppressive therapy

The immune reconstitution syndrome (IRS) is an increasingly recognized disease concept and is observed with a broad-spectrum of immunosuppressive therapy-related opportunistic infectious diseases and severe drug eruptions complicated by viral reactivations. Clinical illness consistent with IRS includes tuberculosis, herpes zoster, herpes simples, cytomegalovirus infections and sarcoidosis: thus, the manifestations of this syndrome and diverse and depend on the tissue burden of the preexisting infectious agents during the immunosuppressive state, the nature of the immune system being restored, and underlying diseases of the hosts. Although IRS has originally been reported to occur in the setting of HIV infection, it has become clear that the development of IRS can also be in HIV-negative hosts receiving immunosuppressive agents, such as prednisolone and tumor necrosis factor α inhibitors, upon their reduction and withdrawal. Drug-induced hypersensitivity syndrome, a life-threatening multiorgan system reaction, is another manifestation of the newly observed IRS. Clinical recognition of the IRS is especially important in improving the outcome for diseases with an otherwise life-threatening progenosis. Clinicians should be aware of the implications of IRS and recognize that relieving the symptoms and signs of immune recovery by anti-inflammatory therapies needs to be balanced with anti-microbial therapies aiming at reducing the amplitude and duration of tissue burden of preexisting microbes.

Unmasking tuberculosis-associated immune reconstitution inflammatory syndrome in HIV-1 infection after antiretroviral therapy

The exaggerated immune response to the subclinical opportunistic microorganisms or their antigens can be found in HIV-1 infected patients after receiving antiretroviral (ARV) therapy. We report a case of unmasking tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) in the HIV-1 infected patient who had no previous history of mycobacterial infection. She had tuberculosis of intestines, peritoneum and mesenteric glands within 2 months of ARV. However, her sputum acid-fast bacilli stain, sputum, blood and cervical lymph node aspiration cultures for mycobacterium were negative. Her CD4 cell count increased of from 46 cells/microL at baseline before receiving ARV to 155 cells/microL at month 6 of ARV. In addition, her plasma pro-inflammatory (IFN-gamma and TNF-alpha) and anti-inflammatory (IL-10) cytokine measurement was supported the occurrence of immune restoration reaction. Therefore, the changing in these cytokine profiles may be an important marker of developing unmasking TB-IRIS.

Neuroradiological features of the tuberculosis-associated immune reconstitution inflammatory syndrome

SETTING

Paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is an important complication in human immunodeficiency virus type I (HIV-1) infected tuberculosis (TB) patients who start combination antiretroviral treatment (ART). Neurological manifestations occur in more than 10% of TB-IRIS cases. Apart from a few case reports, the radiological features of neurological TB-IRIS have not been described.

OBJECTIVE

To describe the neuroradiological findings of patients with paradoxical neurological TB-IRIS.

DESIGN

Computed tomography (CT; n = 13) and magnetic resonance imaging (n = 3) findings of 16 patients were reviewed.

RESULTS

IRIS manifestations included meningitis (n = 4), intracranial space occupying lesions (SOLs, presumed tuberculomas; n = 5), meningitis and SOLs (n = 5), radiculomyelitis (n = 1) and spondylitis (n = 1). In patients with tuberculoma IRIS, we observed a high prevalence of 1) low density lesions on non-contrast-enhanced CT (all lesions), 2) multiple lesions (in 5/10 patients) and 3) perilesional oedema (17/22 lesions). In patients with meningitis, meningeal enhancement (n = 2) and hydrocephalus (n = 1) were infrequently observed.

CONCLUSION

This is the first substantial series to describe the radiological features of paradoxical neurological TB-IRIS. Compared to published radiological findings of tuberculomas in HIV-1-infected patients (not receiving ART), an increased inflammatory response is suggested in tuberculoma IRIS. However, this was not observed in patients with TB meningitis IRIS.