A 46-year-old woman presented with dysphagia secondary to an esophageal stricture. She was incidentally found to have enlarged left supraclavicular lymph nodes. Six months earlier, she had been diagnosed with acquired immunodeficiency syndrome (AIDS) during hospitalization for Pneumocystis jirovecii pneumonia. Her CD4 count was 1 cell/mm3; viral load was 171,579 copies/ml. She was started on antiretroviral therapy and prophylactic doses of trimethoprim/sulfamethoxazole and azithromycin.
Physical exam revealed multiple, 3–4-cm, non-tender, soft, mobile, left supraclavicular lymph nodes. Neck computed tomography (CT) showed numerous enlarged necrotic lymph nodes (Fig. 1); 3 cm3 of purulent material was aspirated on lymph node biopsy. Fluid culture grew Mycobacterium avium complex (MAC), confirming MAC lymphadenitis secondary to immune reconstitution inflammatory syndrome (IRIS).
Soft tissue neck CT showing numerous necrotic lymph nodes in the left supraclavicular area.
IRIS is a paradoxical worsening of a preexisting inflammatory condition that arises after starting highly-active antiretroviral therapy (HAART).1 – 5 Initiation of HAART leads to improvement in host immune function, thereby causing previously subclinical infections to become clinically apparent. Risk factors for IRIS include lower CD4 count at time of therapy initiation and higher potency of HAART regimen.1 , 3 – 7 IRIS secondary to MAC infection generally presents as peripheral, intra-thoracic, or intra-abdominal lymphadenopathy.3 It usually occurs within 3 months of HAART initiation, but has been reported to present up to 4 years later.5
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Matusz-Fisher, A., Bodie, W. & Montgomery, T. Immune Reconstitution Inflammatory Syndrome Presenting as Mycobacterium Avium Complex Lymphadenitis. J GEN INTERN MED 32, 712–713 (2017). https://doi.org/10.1007/s11606-016-3956-z
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DOI: https://doi.org/10.1007/s11606-016-3956-z