UNUSUAL PRESENTATION OF IMMUNE RECONSTITUTION INFLAMMATORY SYNDROME (IRIS)

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pneumocystis jirovecii (PJP) can cause a life-threatening opportunistic infection in patients with HIV, especially those not treated HAART and CD4 count less than 200 cells/mcL. Diagnosis of PJP HIV is typically made bronchoscopy very high diagnostic yield bronchoalveolar lavage (BAL). IRIS describes the paradoxical worsening preexisting following initiation (1). We present case an patient PJP-related who presented atypical chest radiograph negative BAL. CASE PRESENTATION: A 48-year-old man to ED for 2-week history subjective fevers, chills, poor appetite, progressively dyspnea, non-productive cough, pleuritic pain associated intermittent myalgias. He had recently started (bictegravir, emtricitabine, tenofovir alafenamide) ten days prior after presenting oropharyngeal candidiasis; at that time his (xray) was normal he denied respiratory symptoms. been prescribed prophylactic trimethoprim-sulfamethoxazole prophylaxis but non-compliant. The hemodynamically stable on presentation, temperature 39°C, oxygen saturation 95% room air. tachypneic rate 26, lungs were clear. Initial workup showed WBC 4.6*10^3 /mcL (78% neutrophils, 17% lymphocytes) absolute lymphopenia 0.75*10^3 /mcL. His 85 cells/mcL viral load 3360 copies/mcL. LDH elevated 1281 units/L. initial blood gas 7.52/22/58 showing alkalosis hypoxemia. xray bilateral coalescing upper lung opacities. prednisone suspected pneumonia along antibiotic coverage community-acquired pneumonia. Bronchoscopy bronchial mucosa minimal secretions. BAL specimens bacterial, fungal, mycobacterial growths. Transbronchial biopsies (TBBx) left lobe revealed GMS stain. DISCUSSION: developed acute hypoxemic failure from soon starting despite x-ray 2 weeks prior. rapid consistent IRIS. Spanish observational study uncommon involving only six cases out 123 (4.9%) (2).Our patient's atypically Typical radiographs PCP show diffuse or perihilar symmetric interstitial changes be reticular, ground glass, granular (3). CONCLUSIONS: Given patients, many physicians defer TBBx these patients. our may suggest need performing REFERENCE #1: Müller M, Wandel S, Colebunders R, et al. Immune reconstitution inflammatory syndrome antiretroviral therapy infection: systematic review meta-analysis. Lancet Infect Dis. 2010;10(4):251-261. doi:10.1016/S1473-3099(10)70026-8 #2: Roade Tato L, Burgos Cibrian J, Curran Fábregas A, HIV-infected Enferm Infecc Microbiol Clin. 2018;36(10):621-626. doi:10.1016/j.eimc.2017.11.002 #3: Boiselle PM, Crans CA Jr, Kaplan MA. changing face carinii AIDS AJR Am J Roentgenol. 1999;172(5):1301-1309. doi:10.2214/ajr.172.5.10227507 DISCLOSURES: No relevant relationships by Reem Al Shabeeb, source=Web Response Daniel Baram, Sandrine Hanna,