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TB-IRIS — SCE Infectious Diseases MCQ

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ModerateHIV MedicineTB-IRISSCE Infectious Diseases

A 29-year-old man with HIV started ART 3 weeks ago (CD4 80, VL 250,000). He now presents with painful cervical lymphadenopathy, fever, and raised CRP. His viral load has dropped to 5,000 copies/mL. CT neck shows multiple necrotic cervical nodes. No prior history of TB or OI. Fine needle aspirate shows granulomatous inflammation with AFB on Ziehl-Neelsen stain. What is the most likely diagnosis?

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Correct answer: B — Unmasking TB-IRIS

This is unmasking IRIS — ART-induced immune reconstitution has revealed previously subclinical TB infection. The falling viral load confirms ART is working. Unmasking IRIS presents as a new OI diagnosis shortly after ART initiation due to restored pathogen-specific immune responses. Paradoxical IRIS would require the patient to have already been on TB treatment before ART. Management is to start anti-TB therapy and continue ART. Corticosteroids may be added if IRIS is severe.

Reference: BHIVA 2022 – TB/HIV co-infection guidelines; NICE NG33 2016 – TB