Immune reconstitution syndrome (IRIS) in a child with disseminated tuberculosis

IRIS is a paradoxical reaction initially described in HIV-infected patient after initiation of antiretroviral therapy (ART). Incidence is estimated between 12 to 19% in children starting ART. TB associated IRIS is characterized by a clinical worsening after the start of ART in patients receiving Tb treatment. It can also be diagnosed as a new presentation of Tb that is “unmasked” in the weeks following initiation of ART and exclusion of other causes that could explain a deterioration (such as antimicrobial drug resistance, drug hypersensitivity reaction, or another opportunistic infection). IRIS in association with tuberculosis in non-HIV patients has not been reported in the literature. We report the case of an HIV negative 8 years-old malnourished girl of Haitian origin who developed an IRIS and dilated cardiomyopathy during her treatment for severe disseminated TB (lungs, mediastinal lymph nodes, spleen, liver and kidneys). An antibiotic treatment consisting of Rifampine, Izoniacid, Pyrazinamide and Ethambutol (RIPE) for the initial 2 months followed by months 10 of RI was begun against a drug sensitive mycobacterium tuberculosis strain retrieved in gastric aspirates and urine. The child appeared stable for the 2 first weeks of treatment but her fever kept going. In fact, fever (39–40°C) and rigors persisted on a daily basis with diffuse bone pains, elevated transaminases over the next 5 months together with an initial progression of the chest infiltrates. Sequential abdominal CT and Gallium scans demonstrated a progressive involvement of liver (enlarged liver with multiple nodules), spleen, kidneys, bone marrow and abdomen lymph nodes between 2 weeks and 5 months. An extensive search for other infections turned back negative and a complete immunological work-up was considered normal. At the end of those 5 months, fever vanished and she gradually improved. Chest and abdominal imaging also eventually improved. We concluded from an extensive review of the literature that this case highlights a paradoxical immune mediated reaction similar to the previously described IRIS in HIV infected patients but this time to Mycobacterium Tuberculosis during an appropriate antibiotic treatment. Such an IRIS resulted in an apparent clinical deterioration but turned out not being a failure to treatment. In the future, early recognition of an IRIS in tuberculosis might prevent unnecessary changes in anti-TB regimen.