Title : Catastrophic unmasking: Fatal tuberculosis-associated IRIS presenting as acute liver failure in pregnancy
Abstract:
Background: Immune Reconstitution Inflammatory Syndrome (IRIS) is a severe and potentially fatal inflammatory condition that can occur in severely immunocompromised patients, such as those with HIV, after initiating antiretroviral therapy (ART). The syndrome is triggered by a restored immune system recognizing and over-reacting to pre-existing opportunistic pathogens. Tuberculosis-associated IRIS (TB-IRIS) poses a significant diagnostic and therapeutic challenge, particularly in pregnancy, where physiological changes, limited treatment options, and considerations for both maternal and fetal health add layers of complexity. This case highlights the catastrophic presentation of TB-IRIS as fulminant hepatic failure in a pregnant patient newly started on ART.
Methods: This is a case report of a 30-year-old female, at 28 weeks of gestation, who was recently diagnosed with HIV during prenatal screening and initiated on ART. Four weeks after starting treatment, she presented with a history of intermittent fever, productive cough, night sweats, and significant weight loss. Her condition acutely worsened with the onset of jaundice and altered mental status. On admission, she was febrile and exhibited signs of severe illness, including icteric sclerae and bibasal crackles. Laboratory investigations revealed pancytopenia, severe transaminitis, hyperbilirubinemia, and coagulopathy. A chest X-ray showed bilateral pneumonia, and Mycobacterium tuberculosis was confirmed via PCR from sputum and later from ascitic fluid. Her CD4 count was critically low at 8%.
Results: The patient was diagnosed with disseminated tuberculosis. However, both her ART and first-line anti-tuberculosis therapy were discontinued due to rapidly deteriorating liver function. Her clinical condition declined, marked by fetal distress, which necessitated an emergency Cesarean section. Post-operatively, she remained critically ill with persistent fever, worsening coagulopathy, and the development of ascites and encephalopathy, consistent with acute liver failure. The diagnosis of TB-IRIS was made based on the paradoxical clinical deterioration following the initiation of ART in the setting of active tuberculosis. Despite aggressive multi-disciplinary supportive care, the patient developed disseminated intravascular coagulation (DIC) and progressive hepatic failure, ultimately leading to cardiac arrest and death.
Conclusion: This case underscores the diagnostic complexity and devastating potential of TB-IRIS, especially in the vulnerable population of pregnant women with advanced immunosuppression. The exaggerated inflammatory response can mimic other conditions and lead to catastrophic outcomes like fulminant liver failure. It highlights the critical importance of screening for latent and active opportunistic infections, such as tuberculosis, before initiating ART in high-risk patients. Clinicians should maintain a high index of suspicion for IRIS in patients who show paradoxical worsening after starting therapy, as early recognition and management are paramount to improving outcomes in this challenging clinical scenario.
