Introduction
Tuberculosis-immune reconstitution inflammatory syndrome (TB-IRIS) is an excessive immune response against Mycobacterium tuberculosis, and it may occur in either human immunodeficiency virus-infected or uninfected patients, during or after anti-tuberculosis therapy completion. The incidence of tuberculosis in Korea is 76.8 per 100,000 as of 2016, and tuberculous meningitis accounts for 0.7% of all tuberculosis patients. Treatment of tuberculous myelitis is based on the use of anti-tuberculosis drugs and steroids. Long-term use of steroids may cause immune deficiency, and subsequent TB-IRIS. Treatment for TB-IRIS has not been established yet. Steroids can be tried but discontinuation is not easy even the concern about iatrogenic Cushing syndrome. We report a case of TB-IRIS patient whose steroid treatment was successfully changed to non-steroidal anti-inflammatory drugs (NSAIDs).
Case report
The patient was a 26-year-old woman who had no significant past medical history. The patient admitted to the Department of Neurology at the address of weakness both legs. Tuberculous myelitis was diagnosed, and the patient was treated with dexamethasone. After acute management, she was transferred to Department of Rehabilitation Medicine and steroids were tapered gradually. Two months after the onset, fever and TB-re-positive sputum were developed. She was a patient with long-term use of high-dose steroids, and was diagnosed with IRIS due to immunosuppression. She was transferred to the Department of Infection and isolated, and steroids dose was increased. Two weeks after, she was transferred to the Department of Rehabilitation Medicine again. Sputum was TB-negative, however intermittent fever was noted. To prevent iatrogenic Cushing syndrome, NSAIDs (Naproxen 500mg twice a day) were tried. About 4-day overlap period, steroids were quitted. There were no fever symptoms afterwards. Side effects of NSAIDs use were not observed.
Discussion
In general, studies have shown that tuberculosis-induced IRIS can occur in immunocompromised acquired immune deficiency syndrome (AIDS) patients. This patient was HIV-negative, and TB-IRIS appears to be caused by long-term steroids use. In case of TB-IRIS, NSAIDs can be an option which can be used instead of steroids use or can be changed from steroids.
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