Cryptococcal immune reconstitution inflammatory syndrome presenting with erosive bone lesions, arthritis and subcutaneous abscesses

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University of Cape Town

A 35-year-old South African man was diagnosed with pulmonary tuberculosis (TB) in August 2007 and started on a 6-month course of treatment (intensive phase of rifampicin, isoniazid, ethambutol and pyrazinamide for 2 months, followed by continuation phase of rifampicin and isoniazid for 4 months). His TB symptoms responded rapidly. At the time of TB diagnosis, he tested HIV positive. His CD4 cell count was 12 cells/µl with a viral load of more than 500 000 copies/ml. He commenced antiretroviral therapy (ART) 6 weeks later (stavudine, lamivudine and efavirenz). After 16 weeks on ART, his CD4 cell count was 62 cells/µl with an HIV viral load of less than 50 copies/ml. Five months after starting ART and having recently completed his TB treatment, he presented to his local clinic with pain and swelling of the left hypothenar eminence. He was referred to the specialist Hand Clinic, and incision and drainage was performed. Ten days later, this was repeated due to recurrence of symptoms. He experienced no further problems, and remained compliant on ART. Six months later, he presented to our hospital for the first time with tender red subcutaneous abscesses over his sternal notch (Fig. 1a) and in his left flank. His left elbow was swollen, red and extremely painful, with a severely restricted range of movement. A radiograph of the left elbow showed a lytic lesion in the posterior periarticular aspect of the humerus and erosion of the proximal end of the radius with loss of joint space (Fig. 1b). A chest radiograph showed a pulmonary infiltrate in the base of the left lung and erosive lesions in the left 5th and 6th ribs on the lateral film (Fig. 1c). Six weeks prior to this presentation, his CD4 cell count had been 81 cells/µl, and viral load less than 50 copies/ml.