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TB-IRIS Lymph Node Aspiration — SCE Infectious Diseases MCQ

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ModerateTuberculosisTB-IRIS Lymph Node AspirationSCE Infectious Diseases

A 30-year-old man with HIV develops Mycobacterium tuberculosis lymphadenitis. He is started on RHZE and ART simultaneously. Four weeks later, his cervical lymph nodes enlarge dramatically and one develops a fluctuant swelling that discharges spontaneously. He is afebrile with falling CRP. What is the management of the draining lymph node?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: C — Aspirate the fluctuant node (through intact skin to prevent sinus formation) and continue both TB treatment and ART — this is a paradoxical reaction, not treatment failure

Explanation lettering: C = shown as A · E = shown as B · A = shown as C · B = shown as E

Paradoxical TB-IRIS in lymph node TB: dramatic lymph node enlargement, new node formation, or abscess/sinus development DURING effective TB treatment and ART. The falling CRP and afebrile status confirm treatment is working. Management: continue both TB treatment and ART, aspirate fluctuant nodes (needle aspiration through intact skin — do NOT I&D as this causes chronic sinuses), and add corticosteroids (Prednisolone 1.5 mg/kg for 2 weeks then taper) if IRIS is severe (airway compromise, organ dysfunction).

Reference: NICE NG33 2016 – TB; BHIVA 2022 – IRIS; BTS 2024