Immune reconstitution inflammatory syndrome (IRIS) describes a constellation of inflammatory symptoms that develop following the initiation of antiretroviral
therapy (ART) in patients with advanced human immunodeficiency virus (HIV). Here, we present a case of a 39-year-old male-to-female transgender patient with advanced HIV who was started on ART during a hospitalization for acute
encephalopathy due to a combination of methicillin-resistant Staphylococcus aureus (MRSA)
meningitis and
varicella encephalitis. After adequate treatment of these
infections and five weeks after initiation of ART, she developed inflammatory symptoms of malaise,
fever, and
tachycardia, as well as laboratory findings of
leukocytosis consistent with an inflammatory process. Infectious workup did not reveal any evidence of a new
infection, and no other undiagnosed inflammatory processes were discovered to explain these symptoms. A diagnosis of IRIS was suspected, possibly induced by a prior
varicella infection. Diagnosis of IRIS can be difficult due to heterogeneous symptoms, differing etiologies, variable patient presentations, and the lack of universal diagnostic criteria. As instances of IRIS are not uncommon in patients with a low CD4 count who start on ART, there should be a high index of suspicion when patients present with inflammatory symptoms after initiation of ART. With increased recognition of the disease and improved standardization of diagnostic criteria, more could be understood about the underlying disease process which may allow for better targeted
therapies and individualized treatments for patients who develop the
immune reconstitution inflammatory syndrome.