Introduction: The incidence of HIV and AIDS has decreased dramatically in the last two decades with the increasing availability of antiretroviral therapy (ART). Despite this, HIV and its associated conditions can still cause serious illness. Immune reconstitution inflammatory syndrome (IRIS) can occur with the recovery of immune function after the initiation of ART. This can present either as the unmasking of previously unrecognized or worsening of already diagnosed infections.
Description: A 37-year-old male presented with fatigue, nausea, rash, and syncope. The rash began after treatment with amoxicillin for group A strep and persisted despite treatment with corticosteroids. He reported a one-time sexual encounter with a man. He was hypoxic, requiring 3L oxygen. CT chest revealed bilateral ground-glass opacities with mild mosaic attenuation in both lungs, sparing the lung apices and lung base periphery. He was diagnosed with HIV/AIDS with a CD4 count of 31/mm3. and viral load of 1,140,000 copies. CRP was elevated to 137mg/L. The patient was started on ART, sulfamethoxazole/trimethoprim for Pneumocystis Jirovecii Pneumonia (PJP), and azithromycin for Mycobacterium Avium Complex (MAC) prophylaxis. The rash improved, but the patient developed fevers and worsening hypoxia. He underwent a bronchoscopy with BAL, and PJP DFA was positive. The patient was started on intravenous(IV) corticosteroids. Oxygen requirements improved, and steroids were slowly tapered from IV to oral. On day 10 of admission, oxygen requirements worsened despite appropriate treatment of PJP. Repeat CT chest showed progression of bilateral ground glass opacities. Corticosteroid dose was increased and switched to IV for treatment of IRIS. He responded well and was then transitioned to a prolonged taper of oral corticosteroids. He was weaned down to 3L oxygen and discharged home. At outpatient follow-up several weeks later, his viral load was 538 copies and CD4 count 65/mm3.
Discussion: PJP-IRIS is an uncommon complication of HIV-associated infections. This syndrome should be considered in patients experiencing a paradoxical worsening of symptoms after initiation of PJP treatment and ART. Higher doses and/or longer courses of corticosteroids may need to be considered in these patients who are not progressing as expected.
