HIV infected man with pulmonary infiltrates

A 40 year old man from Assam presented with low grade fever, cough and 20 kg weight loss over the past 1 year. Nine months prior to presentation, the patient was diagnosed with smear negative pulmonary tuberculosis. Antituberculous therapy (HRZE) was started, however hepatitis developed and the patient was switched to a streptomycin, levofloxacin and ethambutol regimen. Compliance with treatment was good.

On examination the patient was emaciated. Nodular lesions were noted on the face and upper chest. There was no lymphadenopathy. Chest auscultation revealed bilateral rhonchi and coarse crepitations. The chest radiograph revealed extensive infiltrates on the HIV ELISA was positive for HIV-I antibodies. The patients CD4 count was 23 cells/μl. The HIV-I viral load was 220,000 copies/ml. A CT scan of the chest revealed extensive infiltrates and bronchiectasis in both lungs. Broncheoalveolar lavage was negative for acid fast bacilli. Xpert MTB RIF on BAL fluid was negative for mycobacterial DNA.

Biopsy of the nodular lesions on the face showed granulomatous inflammation with intracellular yeast forms suggestive of Histoplasma capsulatum. Fungal cultures from biopsy sample were negative.

The patient was started on intravenous liposomal amphotericin B for 2 weeks followed by oral itraconazole.

HIV/AIDS WHO stage IV with disseminated histoplasmosis

Disseminated lymphadenopathy in a HIV infected patient

A 37 year old man from Tamil Nadu presented with low grade fever and 8 kg weight loss since 2 months. Examination revealed non-tender cervical lymphadenopathy. HIV ELISA was positive for HIV-I antibodies. The CD4 count was 86 copies/μl. The HIV-I viral load was 73000 copies/ml. Fine needle aspiration cytology of cervical lymph nodes revealed granulomatous inflammation with negative Ziehl Neelsen stains. Xpert MTB RIF on the cervical node sample was positive for mycobacterium tuberculosis DNA with no rifampicin resistance.

Antituberculous therapy (HRZE) in doses appropriate for the patient’s weight was started. The patient showed marked clinical improvement over the course of following 4 weeks. Antiretroviral therapy (tenofovir, emtricitabine, efavirenz) was started after 4 weeks of antituberculous therapy.

Three weeks later, the patient developed high grade fever, malaise, vomiting with enlargement and tenderness of cervical lymph nodes. Discharging sinuses developed from cervical lymph nodes. Paradoxical TB-IRIS was diagnosed. Prednisolone was started at a dose of 1 mg/kg/day and tapered over the next 8 weeks. Discharging cervical sinuses healed with resultant scarring.

Paradoxical TB-IRIS after starting antiretroviral therapy