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Chest Infections |

Immune Reconstitution Inflammatory Syndrome Presenting as Mycobacterium avium intracellulare Mediastinitis

Mauricio Danckers Degregori*, MD; Courtney McElroy, MPH; George Psevdos, MD; Jeffrey Mueller, DO; Victoria Sharp, MD
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New York University, New York, NY


Chest. 2012;142(4_MeetingAbstracts):161A. doi:10.1378/chest.1380610
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Abstract

SESSION TYPE: Infectious Disease Case Report Posters I

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: We report a case of Immune Reconstitution Inflammatory Syndrome (IRIS) presenting as acute mediastinitis due to Mycobacterium Avium Intracellulare (MAI) in a patient with AIDS.

CASE PRESENTATION: A 25-year-old African American man with AIDS and history of MAI mediastinal lymphadenitis, who self-discontinued HAART and MAI treatment 3 month prior, presents to the hospital with a three-day history of cough, productive, yellow sputum associated temperature of 102°F, shortness of breath, and sporadic stabbing pleuritic chest pain. In an attempt to change his life he had decided to restart HAART 10 days prior to this episode. HAART regimen included lopinavir/ritonavir and lamivudine/zidovudine. No MAI treatment was started at that time. His chest X-ray showed worsening mediastinum widening. Chest CT showed extensive progression of known mediastinal and hilar lymphadenopathy. HAART medications were stopped. Videoscopic-assisted excisional lymph node biopsy of the mediastinum revealed non-caseating granulomatous lymphadenitis with numerous acid-fast bacilli. MAI grew from biopsied lymph node tissue and blood cultures. Treatment for MAI was augmented to include ciprofloxacin in addition to clarithromycin, rifabutin, ethambutol. His symptoms improved and he was discharged on day 14 with the plan to restart HAART as an outpatient. Unfortunately, the patient had multiple complications of his disease over the next three years and died of septic shock secondary to MAI-associated enterocolitis.

DISCUSSION: The rapid course of IRIS-related symptoms in our patient described was likely caused by a high burden of organisms along with immune recovery causing an exaggerated inflammatory response. His paradoxical worsening and new symptoms, including new fever, shortness of breath, and pleuritic chest pain occur 10 days after starting HAART. Any suspected case of IRIS must be distinguished from treatment failure, antimicrobial resistance and non-adherence. HIV viral load suppression of >1 log10 copies/ml is a major criterion for IRIS.1 In our case, no CD4 count or VL was drawn when the patient presented with fever. However, the severity of his symptoms cannot be explained by new infection or side effects of the HAART regimen, and they do not follow the expected acute clinical course of MAI. The sequence of symptom presentation suggests worsening MAI infection that was unmasked by immune reconstitution after starting ART.

CONCLUSIONS: Patients with AIDS who develop IRIS-related MAI mediastinitis have clinical and radiologic findings that aid to its prompt recognition.

1) Bohjanen PR BD. Chapter 18: Immune reconstitution inflammatory syndrome. In: Volberding P SM, Lange J, Greene W ed. Global HIV/AIDS Medicine. Philadelphia: Elsevier; 2008:193-205.

DISCLOSURE: The following authors have nothing to disclose: Mauricio Danckers Degregori, Courtney McElroy, George Psevdos, Jeffrey Mueller, Victoria Sharp

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New York University, New York, NY

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