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AIDS Res Ther. 2012; 9: 17.
Published online May 23, 2012. doi:  10.1186/1742-6405-9-17
PMCID: PMC3427137
Tuberculosis associated immune reconstitution inflammatory syndrome in patients infected with HIV: meningitis a potentially life threatening manifestation
Upasna Agarwal,corresponding author1 Amitabh Kumar,1 Digamber Behera,1 Martyn A French,2 and Patricia Price2
1LRS Institute of Tuberculosis and Respiratory Diseases, Sri Aurobindo Marg, near Qutab Minar, New Delhi, India, 110 030
2School of Pathology and Laboratory Medicine, University of Western Australia, and Department of Clinical Immunology and Immunogenetics, Royal Perth Hospital, Perth, Australia
corresponding authorCorresponding author.
Upasna Agarwal: upasna.ag/at/gmail.com; Amitabh Kumar: ambikr/at/yahoo.com; Digamber Behera: dirlrsi/at/gmail.com; Martyn A French: Martyn.French/at/health.wa.gov.au; Patricia Price: patricia.price/at/uwa.edu.au
Received February 18, 2012; Accepted May 8, 2012.
Abstract
Background
Tuberculosis (TB) is the most common co infection in HIV-infected persons in India, requiring concomitant administration of anti TB and antiretroviral therapies. Paradoxical worsening of tuberculosis after anti-retroviral therapy (ART) initiation is frequently seen.
Objective
To study the frequency, clinical presentation and outcome of paradoxical tuberculosis associated immune reconstitution inflammatory syndrome (TB-IRIS) in HIV infected patients in a TB hospital in North India.
Design
A retrospective chart review of HIV-infected TB patients on anti-tubercular treatment (ATT) at time of ART initiation over a 3 year period. Medical records were reviewed for clinical manifestations and outcome in patients who developed TB-IRIS.
Results
514 HIV-infected patients were enrolled between January 2006 and December 2008. Thirteen (12.6%) of 103 patients who had received ART and ATT simultaneously developed paradoxical TB-IRIS. Clinical presentations of paradoxical TB-IRIS included new lymphadenopathy (n = 3), increase in size of existing lymphadenopathy (n = 3), worsening of existing pulmonary lesions (n = 2), appearance of new pleural effusion (n = 1) and prolonged high grade fever (n = 2). Four patients developed new tubercular meningitis as manifestation of TB-IRIS. Our cases developed TB-IRIS a median of 15 days after starting ART (IQR 15–36). TB-IRIS patients were older (> 35 years) than those with no IRIS (P = 0.03), but were not distinguishable by CD4 T-cell count, duration of ATT before ART or the outcome of TB treatment. Eight (62%) patients had a complete recovery while 5 (38%) patients with TB-IRIS died, of which majority (n = 3) had meningitis.
Conclusions
Paradoxical TB-IRIS is a frequent problem during concomitant ATT and ART in HIV-TB co infected patients in north India. Meningitis is a potentially life threatening manifestation of TB-IRIS.
Keywords: Tuberculosis, HIV, IRIS, Meningitis
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