20 year old with HIV-AIDS and tuberculosis with intracranial involvement (TB meningitis), not on treatment for these things.

Appropriate treatment was started, including TB medications and anti-retrovirals for HIV. 2 weeks later, the patient had decreased levels of consciousness.

Top images [A] show the brain at 3 different levels on postcontrast MRI prior to treatment. Bottom images [B] show the follow-up MRI at the time of worsening neurologic status. There is a clear progression of nodular leptomeningeal enhancement throughout the brain.

Taking the above findings into context with the time of treatment, this was felt to be consistent with immune reconstitution inflammatory syndrome, an exaggerated immune response to a co-infection (TB) when a person’s immune deficiency (HIV-AIDS) is corrected. High-dose steroids were started with significant improvement. One month later, a steroid taper was attempted, but the TB-IRIS relapsed. Ultimately, it took a year of slow taper to get the patient off the steroids while continuing to treat the HIV and TB.