20 year old with HIV-AIDS and tuberculosis with intracranial involvement (TB meningitis), not on treatment for these things.
Appropriate treatment was started, including TB medications and anti-retrovirals for HIV. 2 weeks later, the patient had decreased levels of consciousness.
Top images [A] show the brain at 3 different levels on postcontrast MRI prior to treatment. Bottom images [B] show the follow-up MRI at the time of worsening neurologic status. There is a clear progression of nodular leptomeningeal enhancement throughout the brain.
Taking the above findings into context with the time of treatment, this was felt to be consistent with immune reconstitution inflammatory syndrome, an exaggerated immune response to a co-infection (TB) when a person’s immune deficiency (HIV-AIDS) is corrected. High-dose steroids were started with significant improvement. One month later, a steroid taper was attempted, but the TB-IRIS relapsed. Ultimately, it took a year of slow taper to get the patient off the steroids while continuing to treat the HIV and TB.
For the treatment of pts infected with cns tb now, art is not initiated until around week 8 of tb therapy.
Was IRIS the reason for the initial worsening ? starting HIV medication at the same time as TB medication sounds precipitated, but maybe we just haven’t enough details to judge
Yep, it was. Both were started at the same time.
This was around the time IRIS wasn’t a widely known thing.
What is the cause of the midline-occipital artifact in 2B?
Probably motion artifact from blood flow from the superior sagittal sinus.
Thanks!
For the treatment of pts infected with cns tb, art is not initiated until around week 8 of tb therapy to avoid this very issue.
![HIV-AIDS with tuberculosis with WORSENING symptoms after treatment started. [Neuroradiology] [MR]](https://lemmy.world/pictrs/image/ec75db07-3d00-44be-bc55-bf1d6640e66a.jpeg){kind=link}