A 33-year-old man comes to the office due to fever, malaise, and worsened cough. Six weeks ago, the patient visited the emergency room due to 2 weeks of anorexia, cough, fever, weight loss, and dyspnea. He was hospitalized and found to have a right upper lobe lung infiltrate, acid-fast bacilli in the sputum, a CD4 count of 55/mm³, and an HIV RNA viral load of 125,000 copies/mL. The patient was diagnosed with active pulmonary tuberculosis and HIV infection, and was initiated on antiretroviral therapy and 4-drug tuberculosis treatment. His symptoms steadily improved until 3 days ago when his fever and cough returned. He lives alone but a visiting nurse helps him with his medications; he has taken all medications as prescribed. He has no known drug allergies. The patient has a history of multiple incarcerations and used cocaine heavily in the past. Temperature is 39.6 C (103.2 F), blood pressure is 126/82 mm Hg, pulse is 92/min, and respirations are 20/min. There are no mucosal lesions or skin rash. Lung auscultation reveals right-sided crackles. Heart sounds are normal with no murmur. The abdomen is soft and nontender with no hepatosplenomegaly. Chest x-ray is performed and reveals a larger-sized lung opacity and worsened hilar lymphadenopathy. Laboratory studies show a CD4 count of 220/mm³ and HIV RNA viral load of

Question

A 33-year-old man comes to the office due to fever, malaise, and worsened cough. Six weeks ago, the patient visited the emergency room due to 2 weeks of anorexia, cough, fever, weight loss, and dyspnea. He was hospitalized and found to have a right upper lobe lung infiltrate, acid-fast bacilli in the sputum, a CD4 count of 55/mm³, and an HIV RNA viral load of 125,000 copies/mL. The patient was diagnosed with active pulmonary tuberculosis and HIV infection, and was initiated on antiretroviral therapy and 4-drug tuberculosis treatment. His symptoms steadily improved until 3 days ago when his fever and cough returned. He lives alone but a visiting nurse helps him with his medications; he has taken all medications as prescribed. He has no known drug allergies. The patient has a history of multiple incarcerations and used cocaine heavily in the past. Temperature is 39.6 C (103.2 F), blood pressure is 126/82 mm Hg, pulse is 92/min, and respirations are 20/min. There are no mucosal lesions or skin rash. Lung auscultation reveals right-sided crackles. Heart sounds are normal with no murmur. The abdomen is soft and nontender with no hepatosplenomegaly. Chest x-ray is performed and reveals a larger-sized lung opacity and worsened hilar lymphadenopathy. Laboratory studies show a CD4 count of 220/mm³ and HIV RNA viral load of <10,000 copies/mL. Sputum culture results from his previous hospitalization show acid-fast bacilli sensitive to all tested drugs. Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient with advanced HIV was started on treatment for active pulmonary tuberculosis and HIV infection. Six weeks later, he developed recurrent fever, cough, and worsened pulmonary infiltrate, suggesting immune reconstitution inflammatory syndrome (IRIS). Patients with HIV initiated on antiretroviral therapy experience a potent immune recovery. Within weeks, viral load often becomes undetectable and CD4 counts rise dramatically. The renewed ability to recognize and respond to foreign antigens can result in an overabundant inflammatory response to an ongoing infection, which causes a paradoxical worsening of infectious symptoms. IRIS usually occurs several weeks after antiviral initiation and is most common in those who had low CD4 counts and high viral loads. IRIS is particularly common when patients are started on treatment for both Mycobacterium tuberculosis and HIV. Suspicion should be raised when fever and respiratory symptoms (eg, dyspnea, cough) worsen after several weeks of clinical improvement. As IRIS manifestations are usually transient, no alteration to antiretroviral or antituberculosis treatment is usually necessary. However, symptomatic treatment with nonsteroidal anti-inflammatory drugs or a short-course of corticosteroids can be used in those with bothersome symptoms. (Choices B and C) IRIS is typically self-limited; antiretroviral and antituberculosis therapy should be continued to prevent disease recurrence and progression. Only patients with life-threatening symptoms of IRIS (eg, an enlarging mass threatening the airway) require immediate antiretroviral discontinuation. (Choice D) This patient had acid-fast sputum cultures that showed a drug-sensitive organism at the time of diagnosis, and his symptoms improved with treatment. Additional sputum cultures to test for drug resistance are not required at this time. (Choice E) Patients with advanced HIV can sometimes have multiple infections at once. However, Pneumocystis pneumonia typically causes subacute dyspnea, hypoxia, malaise, and cough with a diffuse interstitial infiltrate on chest x-ray. This patient with acute symptoms and a focal lung opacity several weeks after initiating therapy for both TB and HIV is more likely to have IRIS. Educational objective: Patients with HIV may develop a transient worsening of infectious symptoms several weeks after the initiation of antiretroviral therapy due to immune reconstitution inflammatory syndrome (IRIS). IRIS arises due to the potent immune recovery that quickly occurs after the initiation of antiretroviral therapy. IRIS is typically self-limited and requires no alteration to ongoing treatment. Anti-inflammatory medications are sometimes added if IRIS symptoms are bothersome.

A 33-Year-Old Man Comes to the Office Due to Fever