Journal Article

Neurologic Manifestations of Paradoxical Tuberculosis-Associated Immune Reconstitution Inflammatory Syndrome: A Case Series

Dominique J. Pepper, Suzaan Marais, Gary Maartens, Kevin Rebe, Chelsea Morroni, Molebogeng X. Rangaka, Tolu Oni, Robert J. Wilkinson and Graeme Meintjes

in Clinical Infectious Diseases

Published on behalf of Infectious Diseases Society of America

Volume 48, issue 11, pages e96-e107
Published in print June 2009 | ISSN: 1058-4838
Published online June 2009 | e-ISSN: 1537-6591 | DOI: http://dx.doi.org/10.1086/598988
Neurologic Manifestations of Paradoxical Tuberculosis-Associated Immune Reconstitution Inflammatory Syndrome: A Case Series

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Background. Paradoxical neurologic tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is a potentially life-threatening condition that occurs within 3 months after starting combination antiretroviral therapy (ART). The reports in the published literature are anecdotal, and the prevalence and outcomes of neurologic TB-IRIS are unknown.

Methods. We prospectively assessed patients with suspected TB-IRIS from June 2005 through October 2007 at our hospital in Cape Town, South Africa. We defined paradoxical TB-IRIS and paradoxical neurologic TB-IRIS with use of consensus clinical case definitions. We collected data on tuberculosis diagnosis, ART, details of TB-IRIS diagnosis, other opportunistic infections, corticosteroid use, and outcome.

Results. We reviewed 279 patients with suspected TB-IRIS, 54 (19%) of whom had suspected neurologic TB-IRIS, and 225 (81%) of whom had suspected non-neurologic TB-IRIS. Paradoxical TB-IRIS was diagnosed in 190 patients; 23 (12%) of these 190 patients had neurologic TB-IRIS (95% confidence interval, 7%–17%). Eight had meningitis, 7 had tuberculoma, 5 had both tuberculoma and meningitis, and 3 had radiculomyelopathy. Twenty (87%) of the 23 patients with neurologic TB-IRIS required hospital admission (median duration, 12 days; interquartile range, 6–24 days), and 21 (91%) received corticosteroids (median duration, 58 days; interquartile range, 29–86 days). Outcomes 6 months after the initial assessment for neurologic deterioration were as follows: 16 (70%) of the patients were alive (10 of these patients had documented full physical and mental recovery), 3 (13%) were dead, and 4 (17%) were lost to follow-up.

Conclusions. Paradoxical neurologic TB-IRIS accounts for 12% of paradoxical TB-IRIS cases. Neurologic TB-IRIS causes considerable short-term morbidity but has reasonable long-term outcomes. Further research is needed to devise optimal diagnostic and management strategies for patients with tuberculosis who experience neurologic deterioration after starting ART.

Journal Article.  5870 words.  Illustrated.

Subjects: Infectious Diseases ; Immunology ; Public Health and Epidemiology ; Microbiology

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