Sarcoidosis IRIS — SCE Infectious Diseases MCQ

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HardHIV MedicineSarcoidosis IRISSCE Infectious Diseases

A 50-year-old man with HIV (CD4 380, VL <50 on ART) develops new bilateral inguinal lymphadenopathy. He has no systemic symptoms. FNA shows non-caseating granulomata with no organisms. Serum ACE is mildly elevated. CT chest shows bilateral hilar lymphadenopathy and pulmonary infiltrates. What is the most likely diagnosis?

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Correct answer: A — Sarcoidosis — which can emerge during immune reconstitution in HIV as a form of non-infectious IRIS

Sarcoidosis emerging during immune reconstitution on ART (sarcoidosis-like IRIS) is a well-described phenomenon. As the immune system recovers, granulomatous inflammation can develop against unknown antigens, mimicking or representing de novo sarcoidosis. It typically presents 3–12 months after ART initiation in patients with prior low CD4. Key features: bilateral hilar lymphadenopathy, peripheral lymphadenopathy, non-caseating granulomata on biopsy, elevated ACE. TB must be excluded (negative cultures/PCR in this case). Treatment follows standard sarcoidosis management if symptomatic. ART should continue.

Reference: BHIVA 2022 – IRIS; Lancet HIV 2019 – Sarcoidosis-like IRIS