Q: 44 year old male with history of HIV and drug noncompliance presented to ED with mental status change and seizure. CT scan and MRI were promptly done, and patient is transferred to ICU. Astute radiologist called you to say that there appears to be a huge suspicion of tuberculoma in brain. Infectious disease service is consulted. You noticed that though treatment for tuberculous meningitis is written but no orders are written for HIV antiretroviral therapy (ART). Your thoughts?
Answer: There should be a gap of few weeks between the treatment of tuberculous meningitis and ART. Initiation of ART may be complicated by the immune reconstitution inflammatory syndrome (IRIS), which can manifest as reactivation of latent TB, progression of active TB, or clinical deterioration in patients previously improving on anti-tuberculous therapy.
References:
1. Nahid P, Dorman SE, Alipanah N, et al. Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis. Clin Infect Dis 2016; 63:e147.
2. Pepper DJ, Marais S, Maartens G, et al. Neurologic manifestations of paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome: a case series. Clin Infect Dis 2009; 48:e96.
3. Tuon FF, Mulatti GC, Pinto WP, et al. Immune reconstitution inflammatory syndrome associated with disseminated mycobacterial infection in patients with AIDS. AIDS Patient Care STDS 2007; 21:527.
4. Frequency, severity, and prediction of tuberculous meningitis immune reconstitution inflammatory syndrome. Clin Infect Dis 2013; 56:450.
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