Immune reconstitution inflammatory syndrome-unmasking endophthalmic, lymphadenopathic, and neuromeningeal cryptococcosis in an HIV-infected patient starting highly active antiretroviral therapy

摘要

A 37-year-old homosexual was admitted for dysphagia and cachexia. A diagnosis of HIV infection was made 17 months before [CD4+ 476/mul (21%) and HIV viral load 190,000 copies/ml]. He refused highly active antiretroviral therapy (HAART) and did not return for follow-up. Actually he had oral candidiasis and multiple lymphadenopathies. His CD4 + cell count was 27/mul (2%) and he had an HIV viral load of 6xl06 copies/ml. Hepatitis, syphilis, cytomegaloviras (CMV), Toxoplasma serologies, and a purified protein derivative (PPD) skin test were negative. He started oral fluconazole (100mg/24h) and HAART with tenofovir (300 mg) + emtricitabine (200 mg) + efavirenz (600 mg). Increasing dyspnea and a radiologic interstitial lung pattern developed in the following week. No microorganisms were found in the induced sputum. Empirical therapy for Pneumocystis jiroveci pneumonia with intravenous cotrimoxazol [trimethoprim (TMP) 240/sulfamethoxazole (SMX) 1,200 mg/6h] was started. Dyspnea did not improve and small, painless, nodular skin lesions appeared in his trunk and limbs. Pancytopenia developed and cotrimoxazol was stopped. Increasing vision loss, mostly of the left eye, was reported.