Immune Reconstitution Inflammatory Syndrome (IRIS) Presenting as Bilateral Severe Granulomatous Sclerouveitis in a HIV-Infected Patient with Mycobacterium Tuberculosis Infection: A Case Report

Aim: To report a case of tuberculosis (TB) associated immune reconstitution inflammatory syndrome (IRIS) presenting as rapid progressive bilateral severe granulomatous sclerouveitis.

Presentation of Case: A 26-year-old Human Immunodeficiency Virus (HIV) -infected male who was on antiretroviral therapy (ART) 3 months prior to presentation complained of left acute painful red eye with blurring of vision and floaters. There was severe granulomatous uveitis in both eyes with necrotizing scleritis in the left eye. There was also cervical lymph node that was positive for Mycobacterium tuberculosis. He initially responded well to antituberculosis therapy together with topical steroids and antibiotics, oral non-steroidal anti-inflammatory drugs (NSAIDS) and ART. His vision deteriorated after 6 weeks of treatment. He developed bilateral severe sclerouveitis and marked sclera thinning with self-sealed scleral perforation of the left eye. A diagnosis of IRIS was made and systemic steroid was added. Ocular inflammation was controlled, but his left vision remained poor due to perforated extensive necrotizing scleritis, seclusiopupillae and cataract.

Discussion: Intraocular TB may be presented with aggressive, rapid progression of the disease in HIV –infected patients. ART-associated TB is seen in HIV patients who developed TB after initiation of ART. Subset of ART-associated TB could be due to unmasking IRIS. Patients who were treated for opportunistic infection after ART may develop paradoxical IRIS.

Conclusion: Bilateral severe granulomatous uveitis with necrotizing scleritis is a rare manifestation of TB-related IRIS in an HIV patient. It is a potential sight threatening condition. A close monitoring for the development of IRIS during treatment of HIV is essential to minimize the morbidity.