WBR0701

Author	[[PageAuthor::Mohamed Moubarak, M.D. [1]]]
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Emergency Room
Sub Category	SubCategory::Infectious Disease
Prompt	[[Prompt::30 year old HIV positive man recently diagnosed with tuberculosis, present to ED complaining of increasing fever and fatigue, he said that the cough was improving till 3 days ago when he had sputum and chest pain. Antiretroviral therapy has begun immediately once he was diagnosed with AIDS defining tuberculosis 3 weeks ago, and since then he was taking all his medication regularly. On examination, his temperature is 39°C(103.2 F), blood pressure 130/82 mm Hg, pulse 100/min, respiration is 22/min. Chest X-Ray shows new parenchymal opacities, and worsening intrathoracic lymph node enlargement. Aspiration of the lymph node produces purulent materials with no organisms are seen on acid fast stain. Gram stain and culture of expectoration is negative. His CD4 count at time of diagnosis was 90/mm3 with HIV viral load was 130,000 copies/ml, today his CD4 is 230/mm3 and HIV viral load is < 10,000 copies/ ml. What is the most appropriate management of this condition?]]
Answer A	AnswerA::Replacement the antiretroviral therapy with corticosteroids
Answer A Explanation	[[AnswerAExp::Incorrect Discontinuation of antiretroviral therapy only in life threatening conditions.]]
Answer B	AnswerB::Discontinuation of the antiretroviral therapy
Answer B Explanation	[[AnswerBExp::Incorrect Discontinuation of the antiretroviral therapy may be necessary only if the manifestation of IRIS is life threatening]]
Answer C	AnswerC::Replacement of antibiotics with corticosteroids
Answer C Explanation	[[AnswerCExp::Incorrect Antibiotics should never be stopped, although corticosteroids are used sometimes to minimize the inflammatory response]]
Answer D	AnswerD::Doing blood culture
Answer D Explanation	[[AnswerDExp::Incorrect Once the diagnosis of IRIS is made, all other investigations to find the infection source should be stopped.]]
Answer E	AnswerE::Reassurance and continue the antiretroviral therapy
Answer E Explanation	[[AnswerEExp::Correct As a result of IRIS syndrome, the immune system initiate an inflammatory reactions to the preexisting infection sites. IRIS is self limited and antiretroviral therapy should be continued unless it is a life threatening condition]]
Right Answer	RightAnswer::E
Explanation	[[Explanation::Immune reconstitution inflammatory syndrome (IRIS) is a paradoxical worsening of preexisting infections in HIV positive patients that occur days to weeks after highly active antiretroviral therapy (HAART) begin. The rapid improvement of the immune system initiates inflammatory reactions in the sites of preexisting infections. IRIS is typically self -limited syndrome, the best management is to continue HAART and antibiotics treatment of the underlying infections. Educational Objective: References: ]]
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