Neurologic manifestations of paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome: a case series.
BACKGROUND
Paradoxical neurologic tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is a potentially life-threatening condition that occurs within 3 months after starting combination antiretroviral therapy (ART). The reports in the published literature are anecdotal, and the prevalence and outcomes of neurologic TB-IRIS are unknown.


METHODS
We prospectively assessed patients with suspected TB-IRIS from June 2005 through October 2007 at our hospital in Cape Town, South Africa. We defined paradoxical TB-IRIS and paradoxical neurologic TB-IRIS with use of consensus clinical case definitions. We collected data on tuberculosis diagnosis, ART, details of TB-IRIS diagnosis, other opportunistic infections, corticosteroid use, and outcome.


RESULTS
We reviewed 279 patients with suspected TB-IRIS, 54 (19%) of whom had suspected neurologic TB-IRIS, and 225 (81%) of whom had suspected non-neurologic TB-IRIS. Paradoxical TB-IRIS was diagnosed in 190 patients; 23 (12%) of these 190 patients had neurologic TB-IRIS (95% confidence interval, 7%-17%). Eight had meningitis, 7 had tuberculoma, 5 had both tuberculoma and meningitis, and 3 had radiculomyelopathy. Twenty (87%) of the 23 patients with neurologic TB-IRIS required hospital admission (median duration, 12 days; interquartile range, 6-24 days), and 21 (91%) received corticosteroids (median duration, 58 days; interquartile range, 29-86 days). Outcomes 6 months after the initial assessment for neurologic deterioration were as follows: 16 (70%) of the patients were alive (10 of these patients had documented full physical and mental recovery), 3 (13%) were dead, and 4 (17%) were lost to follow-up.


CONCLUSIONS
Paradoxical neurologic TB-IRIS accounts for 12% of paradoxical TB-IRIS cases. Neurologic TB-IRIS causes considerable short-term morbidity but has reasonable long-term outcomes. Further research is needed to devise optimal diagnostic and management strategies for patients with tuberculosis who experience neurologic deterioration after starting ART.
Pepper
Dominique J
DJ
Infectious Diseases Unit, GF Jooste Hospital, Cape Town, South Africa. dominiquepepper@gmail.com
Marais
Suzaan
S
Maartens
Gary
G
Rebe
Kevin
K
Morroni
Chelsea
C
Rangaka
Molebogeng X
MX
Oni
Tolu
T
Wilkinson
Robert J
RJ
Meintjes
Graeme
G
D000305:Adrenal Cortex Hormones / Q000627:therapeutic use; D000328:Adult; D019380:Anti-HIV Agents / Q000009:adverse effects* / Q000627:therapeutic use; D023241:Antiretroviral Therapy, Highly Active / Q000009:adverse effects*; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D054019:Immune Reconstitution Inflammatory Syndrome / Q000473:pathology* / Q000503:physiopathology*; D008297:Male; D011446:Prospective Studies; D013019:South Africa; D016896:Treatment Outcome; D014375:Tuberculoma / Q000473:pathology / Q000503:physiopathology; D020306:Tuberculosis, Central Nervous System / Q000473:pathology* / Q000503:physiopathology*; D014390:Tuberculosis, Meningeal / Q000473:pathology / Q000503:physiopathology; D055815:Young Adult
D000305:Adrenal Cortex Hormones; D019380:Anti-HIV Agents