Immune Reconstitution Inflammatory Syndrome Presenting as Mycobacterium Avium Complex Lymphadenitis

Journal of General Internal Medicine, Dec 2016

Ashley Matusz-Fisher, Wesley Bodie, Thomas Montgomery

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Immune Reconstitution Inflammatory Syndrome Presenting as Mycobacterium Avium Complex Lymphadenitis

J Gen Intern Med Immune Reconstitution Inflammatory Syndrome Presenting as Mycobacterium Avium Complex Lymphadenitis Ashley Matusz-Fisher 0 Wesley Bodie 0 Thomas Montgomery 0 0 Department of Internal Medicine, Carolinas HealthCare System , Charlotte, NC , USA A ary to an esophageal stricture. She was incidentally 46-year-old woman presented with dysphagia secondfound to have enlarged left supraclavicular lymph nodes. Six months earlier, she had been diagnosed with acquired immunodeficiency syndrome (AIDS) during hospitalization for Pneumocystis jirovecii pneumonia. Her CD4 count was 1 cell/mm3; viral load was 171,579 copies/ml. She was started on antiretroviral therapy and prophylactic doses of trimethoprim/sulfamethoxazole and azithromycin. Physical exam revealed multiple, 3-4-cm, non-tender, soft, mobile, left supraclavicular lymph nodes. Neck computed tomography (CT) showed numerous enlarged necrotic lymph nodes (Fig. 1); 3 cm3 of purulent material was aspirated on lymph node biopsy. Fluid culture grew Mycobacterium avium complex (MAC), confirming MAC lymphadenitis secondary to immune reconstitution inflammatory syndrome (IRIS). IRIS is a paradoxical worsening of a preexisting inflammatory condition that arises after starting highly-active antiretroviral therapy (HAART).1-5 Initiation of HAART leads to improvement in host immune function, thereby causing previously subclinical infections to become clinically apparent. Risk factors for IRIS include lower CD4 count at time of therapy initiation and higher potency of HAART regimen.1,3-7 IRIS secondary to MAC infection generally presents as peripheral, intra-thoracic, or intraabdominal lymphadenopathy.3 It usually occurs within Mycobacterium avium complex; immune reconstitution inflammatory syndrome; human immunodeficiency virus - 3 months of HAART initiation, but has been reported to present up to 4 years later.5 Acknowledgments: The authors declare that there are no other contributors, no funders, and the work has not been presented previously. Conflict of Interest: The authors declare that they do not have a conflict of interest. 1. Bosamiya S. The immune reconstitution inflammatory syndrome . Indian J Dermatol . 2011 ; 56 ( 5 ): 476 . doi: 10 .4103/ 0019 - 5154 . 87114 . 2. Hirsch H , Kaufmann G , Sendi P , Battegay M. Immune reconstitution in HIV-infected patients . Clin Infect Dis . 2004 ; 38 ( 8 ): 1159 . doi: 10 .1086/ 383034. 3. Lawn S , Bekker L , Miller R . Immune reconstitution disease associated with mycobacterial infections in HIV-infected individuals receiving antiretrovirals . Lancet Infect Dis . 2005 ; 5 ( 6 ): 361 . doi: 10 .1016/S1473- 3099 ( 05 ) 70140 - 7 . 4. Manabe Y , Campbell J , Sydnor E , Moore R . Immune reconstitution inflammatory syndrome: risk factors and treatment implications. J Acquir I m m u n e D e f i c S y n d r. 2 0 0 7 ; 4 6 ( 4 ) : 4 5 6 . d o i : 1 0 . 1 0 9 7 / Q A I . 0b013e3181594c8c . 5. Manzardo C , Guardo AC , Letang E , Plana M , Gatell JM , Miro JM . Opportunistic infections and immune reconstitution inflammatory syndrome in HIV-1-infected adults in the combined antiretroviral therapy era: a comprehensive review . Expert Rev Anti Infect Ther . 2015 ; 13 ( 6 ): 751 - 767 . doi: 10 .1586/14787210. 2015 . 1029917 . 6. Phillips P , Bonner S , Gataric N , Bai T , Wilcox P , Hogg R , et al. Nontuberculous mycobacterial immune reconstitution syndrome in HIVinfected patients: spectrum of disease and long-term follow-up . Clin Infect Dis . 2005 ; 41 ( 10 ): 1483 - 1497 . doi: 10 .1086/497269. 7. Shelburne SA , Visnegarwala F , Darcourt J , Graviss EA , Giordano TP , White AC , et al. Incidence and risk factors for immune reconstitution inflammatory syndrome during highly active antiretroviral therapy . AIDS . 2005 ; 19 ( 4 ): 399 - 406 . doi: 10 .1097/01.aids. 0000161769 .06158. 8a .


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Ashley Matusz-Fisher, Wesley Bodie, Thomas Montgomery. Immune Reconstitution Inflammatory Syndrome Presenting as Mycobacterium Avium Complex Lymphadenitis, Journal of General Internal Medicine, 2016, 712-713, DOI: 10.1007/s11606-016-3956-z