A 26-year-old female commenced combination ART in February 2013 with a baseline CD4 count of 63 cells/mm3. She had a productive cough and constitutional symptoms, in February 2013, and Ziehl Neelsen stain showed AFB on a sputum sample. Sensitive mycobacteria tuberculosis was detected on GeneXpert MTB/Rif of expectorated sputum. She was commenced on TB treatment and completed a six-month regimen of rifampicin, isoniazid, ethambutol, and pyrazinamide. After completing TB treatment she developed right sided anterior cervical lymphadenopathy, right upper quadrant abdominal pain, vomiting, and nausea. Fine needle aspiration of the lymph node revealed pus that contained AFBs. Drug resistant TB was the initial consideration and the pus was sent for TB culture.
TB culture failed to grow Mycobacteria tuberculosis; however NTM was detected. The patient was commenced on rifampicin, ethambutol, and clarithromycin, and the lymphadenopathy resolved without further surgical intervention.
She did not have a baseline HIV viral load but she responded very rapidly to ART and had an undetectable viral load within 5 months of treatment. At one-year follow-up her HIV viral load was undetectable, and her CD4 count was 231 cells/mm3. The diagnosis of mycobacteria tuberculosis, made after the initiation of antiretroviral treatment, was probably due to nontuberculous mycobacteria immune reconstitution syndrome or TB/NTM coinfection. The NTM infection was not associated with an increase in viral load or a decline in CD4 count; therefore it is likely that this patient had dual TB/NTM associated IRS, rather than a new opportunistic infection. Serial ART monitoring blood results and TB investigations are presented in Table 2.