Tuberculosis Immune Reconstitution Inflammatory Syndrome in an Immunocompetent Patient

Abstract Tuberculosis-immune reconstitution inflammatory syndrome (TB-IRIS) is an exaggerated inflammatory response to Mycobacterium tuberculosis typically described in HIV-infected patients after initiation of anti-retroviral therapy (ART), as immune function is restored. It is rarely reported in HIV-negative patients, with presentation as paradoxical worsening of tuberculosis following initiation of antimycobacterial treatment. TB-IRIS is often misdiagnosed as treatment failure, drug resistance, superimposed bacterial infection, or malignancies. The case describes IRIS in an immunocompetent patient with drug-sensitive tuberculosis that was managed successfully. Case Presentation A 72-year-old Nigerian female with a recent diagnosis of pulmonary tuberculosis (PTB), on six weeks with Rifampin, Isoniazid, Pyrazinamide, and Ethambutol (RIPE) therapy, presented with dyspnea, fatigue, and edema with prior unintentional 30 pounds weight loss. She was hypoxemic, requiring intubation, and maintained on air-borne isolation. Laboratory work-up revealed a normal WBC and an unremarkable viral panel and HIV Testing. Chest X-ray showed increased confluence of biapical opacities. Chest CT Scan revealed worsening tree-in-bud opacities and consolidation encasing right upper lobe cavitary lesion. Bronchoscopy with right upper lobe bronchoalveolar lavage (BAL) was performed, revealing sparse acid-fast bacilli (AFB) with no other bacterial growth. The patient continued to have recurrent fevers and hypoxemia despite antibiotic coverage, raising concern for tuberculosis-associated immune reconstitution syndrome (TB-IRIS). Due to elevated liver function tests (LFTs), anti-tuberculosis medications were temporarily withheld. She was initiated on oral steroids with prednisone for presumed TB-IRIS. Anti-tuberculosis medications were gradually reintroduced as LFTs improved. The patient's condition improved, and she was extubated on day 7, remained afebrile, and was discharged from the ICU on day 11. Discussion The patient's clinical course, with initial improvement with confirmed adherence to the RIPE therapy regimen but subsequently worsening dyspnea, recurrent fevers, and pulmonary infiltrates with negative infectious work-up suggest a diagnosis of TB-IRIS. Though she was initiated on empirical antibiotics, subsequent bronchoscopy culture data was negative, and she did respond to steroids with resolution of her clinical symptoms and hypoxemia. Currently, there is no test to confirm or rule out the diagnosis of TB-IRIS, nor is there consensus on standard treatment. However, a four-week course of prednisone has been shown to reduce morbidity in patients with TB-IRIS. Conclusion Tuberculosis-immune reconstitution inflammatory syndrome characterized as paradoxical worsening of a Mycobacterium tuberculosis infection following initiation of anti-tuberculosis treatment can occur in both HIV-infected and uninfected patients. Further studies are needed to develop precise diagnostic criteria and optimal treatment modalities.