Virat Sirisanthana, M.D.
| The medications included: | |
| 1. | Anti-tuberculous drugs: INH, rifampicin, pyracinamide, streptomycin IM |
| 2. | Acyclovir eye drop for herpes keratitis |
| 3. | HAART:GPOvir (stavudine, lamivudine and navirapine) |
| > 9 days | after the discharge, she was followed up at the out patient department of a community hospital. The CXR (figure 2) was taken due to her non-specific complaint. She was sent home to continue the same medications. |
| > 38 days | after the discharge, she was admitted to the community hospital because of abdominal discomfort for 5 days PTA. She was afebrile and in respiratory distress. The CXR (figure 3) and abdominal (figure 4) films were taken. She did not responded to supportive treaments and expired on the 6 days of hospitalization. |
 |
Figure 1. The previous CXR: before the discharge from CMU hospital (taken 10 days before the CXR in figure 2) 28 days after starting anti-tuberculous treatment: the "miliary" pattern persisted, although each nodule was smaller in size. At the time HAART was started |
 |
Figure 2. CXR at the community hospital 40 days after starting anti-tuberculosis treatment 12 days after HAART was started 10 days after the discharge There was widening of the mediastinum which indicated thoracic adenopathy. There was an increasing density of nodules in both lungs which represented worsening of the pulmonary parenchymal disease. (although, it might partly be the effect of the patient's movement and the under-exposure of the film) |
 |
Figure 3. CXR at the community hospital when she was admitted. 70 days after starting anti-tuberculous treatment 41 days after HAART was started Right pleural fluid was seen. The previous "miliary pattern" was not clearly seen. |
 |
Figure 4. Abdominal X-ray at the community hospital when she was admitted. 70 days after starting anti-tuberculosis treatment 41 days after HAART was started The film showed evidence of ascites. |
|
Discussion: Although the repeated CD4 cell count and viral load (VL) were not done. The diagnosis of "Immune Reconstitution Imflammatory Syndrome" (IRIS) was the most likely diagnosis. |
| > | After the use of highly active antiretroviral therapy (HAART), there has been a decrease in the incidence of opportunistic infections among HIV-infected patients. However, experience during the past several years has disclosed the emergence, in a small proportion of cases, of a unique set of complications. This phenomenon is now labeled as immune reconstitution inflammatory syndrome (IRIS) |
| > | It is a paradoxical deterioration in clinical status attributable to the recovery of the immune system during HAART |
| > | The manifestations of this syndrome are diverse and depend on the particular infectious agent involved. All of these patients had significant increases in CD4 cells with a marked decreasing in VL. |
| > | The most common presentation of tuberculosis-induced IRIS is transient worsening of the previous pulmonary lesions which commonly occurs 1-5 weeks after starting HAART. The presentations were worsening parenchymal disease, thoracic adenopathy, and pleural effusion. Improvement occurring between 2 weeks and 3 months later. In severe case the patient could also develop ascites (ref. 2). |
| > | Other than supportive and symptomatic managements, corticosteriod may be added in severe cases. |
Suggested reading:
> 1. Shelburne SA 3rd, Hamill RJ, Rodriguez-Barradas MC, et al. Immune
reconstitution inflammatory syndrome: Emergence of a unique syndrome during
highly active antiretroviral therapy. MEDICINE 81:213-27,2002
> Fishman JE, Saraf-Lavi E, Narita M, Hollender ES, Ramsinghani R,
Ashkin D. Pulmonary tuberculosis in AIDS patients: transient chest radiographic
worsening after initiation of antiretroviral therapy. AJR Am J Roentgenol.
2000;174:43-9.
> ÇÔÃѵ ÈÔÃÔÊѹ¸¹Ð. Immune Reconstitution Inflammatory Syndrome ã¹¼Ùé»èÇÂàͪäÍÇÕ·Õèä´éÂÒµéÒ¹äÇÃÑÊ.
·ÇÕ âªµÔ¾Ô·ÂÊع¹·ì, Íѧ¡Ùà à¡Ô´¾Ò³Ôª, ÃѧÊÔÁÒ âÅèËìàÅ¢Ò (ºÃóҸԡÒÃ).
Update on Pediatric Infectious Diseases 2004. ¡ÃØ§à·¾Ï : ºÃÔÉÑ· ÃØè§ÈÔÅ»ì¡ÒþÔÁ¾ì
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