CRP1 REFRACTORY TUBERCULOSIS-IRIS WITH MULTIORGAN COMPLICATIONS: A PEDIATRIC CASE REPORT ON MANAGEMENT COMPLEXITY

Hasmiza, Syaheerah, Mariana
Hospital Raja Perempuan Zainab II, Kelantan, Malaysia

Introduction
Tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is an inflammatory complication arising during effective anti-tuberculosis therapy, typically seen in patients with retroviral disease (RVD). It is uncommon in RVD-negative individuals and can pose significant diagnostic and therapeutic challenges, particularly in pediatric patients.

Case Report
We report a 10-year-old RVD-negative boy who presented with chronic cough and respiratory distress. Chest imaging revealed a left-sided pleural effusion, and Mycobacterium tuberculosis was confirmed via sputum analysis. He was started on standard anti-tuberculosis therapy (EHRZ) and intravenous corticosteroids. Within days, he developed acute respiratory distress syndrome (ARDS) and pulmonary hemorrhage, requiring mechanical ventilation and inotropic support. His condition was further complicated by recurrent pneumothorax and tuberculous meningitis, confirmed by MRI findings of cerebral infarctions, hydrocephalus, and cerebral oedema. Neurological recovery remained slow despite corticosteroids, and further deterioration occurred during steroid tapering. High-resolution chest CT showed progressive fibrotic changes, and echocardiography showed chronic pericarditis. By the third month of therapy, he experienced worsening respiratory symptoms and new pulmonary infiltrates, consistent with steroid-refractory TB-IRIS. Infliximab was initiated after rheumatology consultation. By week six, he showed marked clinical improvement, including oxygen weaning and normalization of breath sounds.

Discussion
This case highlighted the rare and often overlooked occurrence of TB-IRIS in immunocompetent children. Its progression despite corticosteroid treatment underscores the importance of early intervention and the potential need for biological therapy.

Conclusion
A high index of suspicion, multidisciplinary care, and timely use of biologic therapy such as infliximab may be considered to mitigate steroid-related toxicity and improve clinical outcomes