A 34-year-old man comes to the emergency department after coughing up blood-streaked, white sputum this morning, following a week of malaise and productive cough. Two months ago, he was evaluated for weight loss and oral thrush and was diagnosed with HIV infection. His initial CD4 count was 55/mm³, and HIV viral load was 1 million copies/mL. Interferon-gamma release assay testing was indeterminate at that time, and he was started on combination antiretroviral therapy and trimethoprim/sulfamethoxazole. The patient is adherent with his medication regimen.
Temperature is 38 C (100.4 F) , blood pressure is 110/70 mm Hg, pulse is 96/min, and respirations are 16/min. BMI is 17 kg/m². Oxygen saturation is 95% on room air. No thrush is present and no enlarged lymph nodes are palpable. Coarse rhonchi are heard over the left upper lung field. There are no skin rashes or edema. Leukocyte count is 5,500/mm³, and chest x-ray reveals a dense consolidation in the left upper lobe. CD4 count is now 240/mm³.
Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

This patient was recently diagnosed with HIV and started on antiretroviral therapy (ART). He now likely has immune reconstitution inflammatory syndrome (IRIS) due to previously undiagnosed tuberculosis (TB). IRIS is characterized by paradoxical worsening of a preexisting chronic infection or unmasking of an unrecognized infection due to immune system recovery during the treatment of HIV. Patients usually develop IRIS within a few weeks or months of ART initiation. Most cases arise in patients with pretreatment CD4 counts of <100/mm³. Severity is usually greatest in those with high pretreatment HIV RNA levels who have a strong virologic (rapid decline in HIV RNA) and immunologic (rapid rise in CD4 count) response to therapy. Because IRIS is a diagnosis of exclusion, other conditions (eg, bacterial superinfection, drug allergy/toxicity, patient noncompliance) must be considered. ³ Several opportunistic infections have been associated with IRIS, including: Mycobacterium tuberculosisCryptococcusCytomegalovirusHepatitis B and CHerpes simplex virusHuman herpes virus 8John Cunningham polyomavirusPneumocystis Mycobacterium tuberculosis Cryptococcus Cytomegalovirus Hepatitis B and C Herpes simplex virus Human herpes virus 8 John Cunningham polyomavirus Pneumocystis IRIS is typically self-limited and is primarily addressed by treating the underlying infection. ART can usually be continued without interruption, but patients who develop life-threatening complications (eg, airway obstruction due to an expanding inflammatory mass) often have to transiently stop ART (Choice C). Corticosteroids are generally not indicated but can be added for patients with severe or life-threatening symptoms (eg, obstructive mass lesions) (Choice D). (Choice A) The patient had an indeterminate interferon-gamma release assay (IGRA) and now has manifestations (eg, cough, upper lobe infiltrate) of active TB infection; as a result, symptomatic care alone is inappropriate. He should undergo sputum testing for acid-fast bacilli and culture to establish a microbial diagnosis. (Choice E) Patients with HIV who have low CD4 counts are more likely to have indeterminate IGRA testing; therefore, IGRA is often repeated when CD4 counts improve. However, this patient now has symptoms and chest x-ray findings consistent with active TB; as a result, additional latent TB screening (with repeat IGRA) would not be indicated at this time. He should undergo sputum testing to establish a microbial diagnosis. Educational objective: Patients with HIV who have low CD4 counts (usually <100/mm³) and high pretreatment HIV RNA levels are at greatest risk for immune reconstitution inflammatory syndrome, which is characterized by paradoxical worsening of a preexisting chronic infection or unmasking of an unrecognized infection within weeks or a few months of antiretroviral initiation. Treatment is generally focused on the underlying infection; antiretroviral therapy (ART) can usually be continued without interruption. However, patients with severe or life-threatening complications may require the temporary cessation of ART and/or the addition of corticosteroids. ³ __________ References: Management of the immune reconstitution inflammatory syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/22752438) The immune reconstitution inflammatory syndrome related to HIV co-infections: a review. (http://www.ncbi.nlm.nih.gov/pubmed/21964588)

A 34-Year-Old Man Comes to the Emergency Department After Coughing