Date Published: September 28, 2011
Publisher: BioMed Central
Author(s): Bo K Mortensen, Susanne D Nielsen, Charlotte B Christensen, Jannik Helweg-Larsen.
We report an unusual case of HIV-related immune reconstitution inflammatory syndrome, presenting as suspected AIDS-related lymphoma. Symptoms, initial investigations including fine-needle biopsy and 18F-FDG PET/CT scan were highly compatible with high grade AIDS-related lymphoma, however subsequently IRIS was diagnosed. We discuss pitfalls in the interpretation of diagnostic results in ARL versus IRIS.
Immune inflammatory reconstitution syndrome (IRIS) in HIV patients after initiation of combination antiretroviral therapy (cART) has been increasingly recognized. IRIS is defined as a paradoxical worsening or unmasking of infections, autoimmune diseases or tumours after initiating of cART, and is usually seen when the initial CD4 count is low. The pathological basis is thought to be recovery of the immune system, and IRIS is often described to occur in patients infected with mycobacteria. The diagnosis of IRIS is often challenging as differential diagnosis is complex, including opportunistic infection, drug failure/toxicity or malignancy. The most common symptoms seen in IRIS are fever, lymphadenopathy and pulmonary symptoms  which resemble symptoms seen in patients with AIDS related lymphoma (ARL). In the literature, cases of IRIS, mimicking relapse of ARL have been described . In addition, high rate of ARL has recently been reported shortly after initiation of newer-class antiretrovirals  which makes the distinction between ARL and IRIS important. As seen in the present case report, the distinction between ARL and IRIS may cause major difficulties.
A 37-year homosexual male was admitted to a Gastroenterology Clinic because of six weeks of non-bloody diarrhea, abdominal pain and marked weight loss. Findings at sigmoideoscopy suggested Crohns Disease. After one month of steroid treatment most symptoms had subsided with colonoscopy and x-ray of the small intestine then demonstrating only mild colitis without involvement of the terminal ileum. In the following weeks, steroids were completely tapered; however HIV-testing was not performed.
The present case demonstrates pitfalls in interpretation of the standard techniques when diagnosing a patient with ARL versus IRIS.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images.
The authors declare that they have no competing interests.
All authors contributed to the manuscript. BM was responsible for the final manuscript, CC provided PET-CT images and interpretation. JH and SN were responsible for the primary management of the patient. JH has given the final approval of the version to be published. All authors have read and approved the final manuscript.