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Efavirenz/lamivudine/tenofovir-disoproxil-fumarate Immune reconstitution inflammatory syndrome associated Pneumocystis jirovecii pneumonia: case report

A 21-year-old man developed immune reconstitution inflammatory syndrome (IRIS) associated Pneumocystis jirovecii pneumonia during treatment with efavirenz/lamivudine/tenofovir-disoproxil-fumarate for acquired immunodeficiency syndrome (AIDS). The man, who was diagnosed with type I respiratory failure, HIV infection and Pneumocystis jirovecii pneumonia following hospitalisation, started receiving treatment with cotrimoxazole [trimethoprim/sulfamethoxazole] and levofloxacin. After 8 days of the treatment, he recovered. He was discharged with a plan to complete a 21-day course of cotrimoxazole and a 1-week course of levofloxacin. After 3 weeks of the treatment with cotrimoxazole, a chest CT showed resolution of the Pneumocystis jirovecii pneumonia. He was then started on antiretroviral treatment with efavirenz/lamivudine/tenofovir-disoproxil-fumarate [route and dosage not stated]. Five days following the initiation of efavirenz/lamivudine/tenofovir-disoproxil-fumarate, he presented with a high fever, chills, nausea, productive cough and dyspnoea. On presentation, he was afebrile with an oxygen saturation of 87.2% on room air, RR was 20 breaths/minute, HR was 116 beats/minute, and BP was 105/70mm Hg. Thoracic auscultation revealed a "Velcro sound" in the bilateral lower lobes. Blood gas analysis revealed type I respiratory failure. Blood tests revealed elevated levels of CRP, WBC and lactate dehydrogenase. A chest CT showed bilateral diffuse patches with the air bronchogram sign, revealing that the pulmonary infiltrations had worsened compared with the previous chest CT. He received empirical antibiotic therapy with meropenem, levofloxacin, caspofungin, oseltamivir [oseltamivir phosphate] and clarithromycin. However, the empirical antibiotic therapy proved ineffective. To obtain a definite diagnosis and select a targeted treatment, bronchoscopy with radial endobronchial ultrasound (EBUS)-guided lung biopsy were performed. The bronchoscopy revealed increased secretions from different bronchi. The EBUS image revealed heterogeneous internal echoes and an irregular margin of the lesion within the lumen of right bronchus 6 (RB6), with almost no vessels or bronchi within the lesion. Six biopsies were obtained with forceps for histopathological examination. Bronchoalveolar lavage was also performed to identify potential pathogens. Hematoxylin and eosin staining showed consolidation of the lung tissue, proliferated fibrous tissue with inflammatory cell infiltration, and a local pink-stained substance. Histopathologic evaluation of the tissue showed the presence of pneumonitis. Pneumocystis jirovecii pneumonia was subsequently confirmed with a positive result following Gomori’s methanamine silver nitrate staining for Pneumocystis jirovecii in the biopsied specimens and detection of Pneumocystis jirovecii DNA in the bronchoalveolar lavage fluid. A diagnosis of IRIS-associat