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Hepatic MAC-IRIS — SCE Infectious Diseases MCQ

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HardHIV MedicineHepatic MAC-IRISSCE Infectious Diseases

A 40-year-old man with HIV (CD4 180) is started on ART. Two weeks later he develops tender hepatomegaly, fever, and rising ALP with preserved ALT. He has a history of prior MAC prophylaxis (Azithromycin) which was stopped when ART was started. What is the most likely diagnosis?

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Correct answer: D — Hepatic MAC-IRIS — immune reconstitution unmasking subclinical hepatic MAC infection

Hepatic MAC-IRIS presents with tender hepatomegaly, fever, and disproportionately elevated ALP (cholestatic pattern) shortly after ART initiation. It reflects immune reconstitution unmasking previously subclinical hepatic granulomatous MAC infection. The rising ALP with preserved ALT (cholestatic rather than hepatocellular pattern) is characteristic of granulomatous hepatitis. Blood cultures for MAC should be sent. Treatment is standard MAC therapy (Clarithromycin plus Ethambutol) plus continuation of ART. Corticosteroids may be considered for severe IRIS symptoms.

Reference: BHIVA 2022 – OI guidelines; BHIVA 2022 – IRIS