We describe a rare case of central nervous system tuberculosis-related immune reconstitution inflammatory syndrome (CNS-TB-IRIS).

HIV with tuberculosis co-infection is common. Tuberculous meningitis is a rare form of extra-pulmonary tuberculosis with a high morbidity and mortality. Patients must receive both anti-retroviral therapy (ART) and TB treatment (TBT). Since reconstitution of the immune system can exacerbate TB, timing of ART in relation to TBT needs to be carefully considered.

A 58-year-old woman with a history of intravenous drug use presented with a new onset headache and fever. On exam, patient had signs of meningeal irritation. MRI showed leptomeningeal enhancement of the basal meninges. Lumbar puncture showed an OP of 16cmH2O; Glucose: 22; Protein: 437; WBC: 385 (18% segments, 78% lymphocytes, 4% monocytes). Given the CSF pattern, TBT was started with rifampin, isoniazide, pyridoxine, ethambutol and pyrazinamide. HIV-1 Ab was positive with a CD4 count of 125. Cryptococcal Ag, serum RPR, VDRL CSF, fungal cultures, serum toxoplasmosis IgM/IgG and histoplasmosis urine Ag were negative. Quantiferon gold and CSF AFB-culture and stain showed pan-sensitive mycobacterium tuberculosis complex, confirmed by M. tuberculosis amplified probe. ART was added 14 weeks after the initiation of TBT. Three weeks later, she presented with a new onset seizure. CD4 count was 214. Lumbar puncture showed an OP of 19cmH2O; Glucose: 29; Protein: 165; WBC: 7 (13% segments, 85% lymphocytes, 2% monocytes). CSF HSV-PCR, VZV-PCR and cryptococcal Ag were negative as was serum toxoplasmosis IgM/IgG.MRI showed multiple ring-enhancing lesions with marked meningeal enhancement around the basal cisterns.

Our patient was diagnosed with tuberculomas secondary to CNS-TB-IRIS and was discharged to a nursing home on levetiracetam, ART, TBT and a dexamethasone taper. 

This case report illustrates the development of CNS-TB-IRIS, despite the delay of ART in a patient with HIV-related tuberculous meningitis.