Progressive Disseminated Histoplasmosis as Unmasking IRIS in Advanced HIV: A Case Report

Abstract

Immune reconstitution inflammatory syndromes (IRIS) are well documented, but they present challenges in diagnosis and management.  IRIS in patients with acquired immune deficiency syndrome (AIDS) can be characterised by unusual manifestations of opportunistic infections. This case aims to explore progressive disseminated histoplasmosis presenting as unmasking IRIS in a patient with advanced HIV disease. A 23-year-old male patient presented to the hospital with a 7-day history of fever, cough with expectoration, shortness of breath, and progressive weight loss for the past 2 months. The patient also complained of a 2-day history of night sweats, chills and 1 episode of Epistaxis a day before presentation. He was a known case of HIV since birth and had stopped taking anti-retroviral therapy medications for the past 7 years. On examination, he was febrile (104 °F), with normal blood pressure (110/80mm Hg), tachycardic (143 bpm), requiring 4L/minute of oxygen supplementation with the help of nasal prongs. The patient was started on ATT empirically, as the patient showed all clinical features of tuberculosis, even though there was no objective evidence. A request was sent to his ART centre to test for their current CD4 counts and viral load. The patient was symptomatically better on follow-up after 6 weeks. IRIS was unmasked upon initiation of the Tenofovir+ Lamivudine+ Dolutegravir (TLD) regimen of HAART. TLD is a first-line HAART regimen which has shown satisfactory viral suppression rates (>95%) without correlation with age, health status, sex and duration of anti-retroviral therapy. This patient had a presentation of granuloma for which drugs to manage focal seizures- levetiracetam and lacosamide were prescribed. Additionally, anti-tubercular drugs (Tab HRZE) were also prescribed. This case illustrates the potential for progressive disseminated histoplasmosis to emerge as an unmasking IRIS phenomenon in a patient with advanced HIV disease shortly after the initiation of antiretroviral therapy. Increased awareness of the disease condition and its associated factors might improve a clinician’s index towards the suspicion of the disease, which could lead to a better treatment outcome, also reducing the patients’ healthcare costs.