Spontaneous Splenic Rupture as Manifestation of the Immune Reconstitution Inflammatory Syndrome in an HIV Type 1 Infected Patient with Tuberculosis

Spontaneous Splenic Rupture as a Paradoxical Reaction during Treatment for Splenic Tuberculosis

This report describes a rare case of a patient with splenic tuberculosis (TB) who developed spontaneous splenic rupture after 10 weeks of antituberculous chemotherapy. The patient responded well to the antituberculous regimen prior to the spontaneous splenic rupture. We considered a paradoxical reaction as a cause of the splenic rupture. The patient underwent splenectomy and continuously received initial antituberculous drugs without change. To the best of our knowledge, this is the first report of spontaneous splenic rupture as a paradoxical reaction to antituberculous chemotherapy in an immunocompetent host with splenic TB.

Splenic abscess as a paradoxical response to chemotherapy in tuberculous pleural effusion

We report a rare case of tuberculous pleural effusion that developed multiple splenic abscesses after antituberculosis chemotherapy. She responded to addition of oral corticosteroid to antituberculosis regimen. The relevant literature, regarding pathogenesis and clinical importance of recognizing a paradoxical response, is discussed.

Immune reconstitution inflammatory syndrome

Immune reconstitution inflammatory syndrome (IRIS) must be considered in the differential diagnosis for any patient infected with HIV who has begun ART in the preceding months. Distinguishing between manifestations of IRIS and active infection is of paramount importance and poses a diagnostic challenge to the provider in the acute care setting. Presentations of IRIS are often atypical for the precipitating pathogen, and novel presentations are likely. Of the diseases associated with IRIS, mycobacteria and cryptococcal infections are commonly encountered, as are dermatologic symptoms in general. The most clinically significant complications of IRIS are those involving the central nervous system, lungs, and eye, and in many of these scenarios systemic steroids may be of benefit. Management should rarely include interruption of ART, except possibly in severe, life-threatening complications.

Tuberculosis-associated immune reconstitution inflammatory syndrome and unmasking of tuberculosis by antiretroviral therapy

The tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is a frequent early complication of antiretroviral therapy (ART), used to treat HIV-1 infection, especially in countries where TB is prevalent. TB-IRIS is characterized by an exaggerated inflammatory response toward the antigens of Mycobacterium tuberculosis that results in clinical deterioration in patients experiencing immune recovery during early ART. Two forms of TB-IRIS are recognized: paradoxical; and unmasking. Paradoxical TB-IRIS manifests with new or recurrent TB symptoms or signs in patients being treated for TB during early ART, and unmasking TB-IRIS is characterized by an exaggerated, unusually inflammatory initial presentation of TB during early ART. In this review the incidence, clinical features, risk factors, treatment, and prevention of TB-IRIS in adult and pediatric patients are discussed.

Management of individuals requiring antiretroviral therapy and TB treatment

PURPOSE OF REVIEW

Globally, tuberculosis (TB) is the commonest opportunistic infection in people living with HIV. Many co-infected patients first present with advanced immunosuppression and require antiretroviral therapy (ART) initiation during TB treatment. The incidence of TB in patients established on ART remains high. Co-treatment presents several management challenges. Recent data on these management issues are reviewed.

RECENT FINDINGS

Efavirenz concentrations at standard doses are similar with and without concomitant rifampicin-based TB treatment. Nevirapine concentrations are frequently subtherapeutic during lead-in dosing at 200 mg daily in patients on rifampicin-based TB treatment, which may result in inferior virological outcomes. Hepatotoxicity occurred in three pharmacokinetic studies (conducted in healthy volunteers) of boosted protease inhibitors initiated in participants on rifampicin. Results of a clinical trial comparing efavirenz-based and nevirapine-based ART in patients on TB treatment, with no lead-in dosing of nevirapine, are awaited. Concurrent TB treatment increases the need for stavudine substitutions, mainly related to neuropathy. Consensus case definitions for TB immune reconstitution inflammatory syndrome (TB-IRIS) have been published. It is important to exclude TB drug resistance in patients with suspected TB-IRIS. A clinical trial demonstrated benefit of prednisone for treating TB-IRIS, reducing a combined endpoint of days of hospitalization and outpatient therapeutic procedures. Starting ART during TB treatment improved survival in patients with CD4 cell count less than 500 cells/mul, but the optimal interval between starting TB treatment and starting ART remains to be determined in several ongoing trials.

SUMMARY

ART improves survival in co-infected TB patients, but is complicated by several management challenges that compromise programmatic implementation in resource-limited settings. Recent findings and the findings of ongoing studies will assist clinicians in dealing with these challenges.