A 33 year-old male patient living with HIV/AIDS, visits Merpati Clinic at Wangaya Hospital in Denpasar, Bali, Indonesia, every month routinely. On May 6, 2019, he presented with prolonged fever, chronic cough, night sweats, decrease of appetite, decrease of body weight and no enlargement of lymph nodes. The past medical history was confirmed with HIV infection. There were other family members with the same complaint. Vital signs of the patients were: body temperature 37.8 C, arterial blood pressure: 120/70, and heart rate: 96/min regularly. On physical examination we found rales in chest auscultation at both sides, no lymph node enlargement. On the chest X-ray there were infiltrates in both of the lungs (Figure 1).
The laboratory results found no increase of white blood cells, no thrombocyte abnormality and no anemia. The peripheral smear showed no abnormality, without atypical cells. No hepatic function, no electrolyte and no renal function abnormalities were reported. Erythrocyte sedimentation level was 48 (normal range: 0-20 mm/h). With CD4 T cell depletion, the number of CD4 was 150 cell/microL and Xpert HIV-1 viral load of 5.3 log10 copies/mL.
The working diagnosis was HIV-infected patient (WHO stage IV) and confirmed with active pulmonary TB and he was treated with antituberculosis drugs (ATDs).
On July 3, 2019, at the end of the intensive phase (eight weeks after taking ATD treatment), the patient's condition had stabilized or improved; clinically he felt better (no cough, no fever, no night sweats, no decrease in appetite, no enlargement of lymph nodes). The number of CD4 was decreased: 150 to 53 cells/microL. Xpert HIV-1 viral load was increased to 5.8 log10 copies/mL. Chest X-ray showed no abnormality (Figure 2).
The conclusion was TB improvement (had stabilized) and he had been started on HAART with fixed dose combination/FDC (tenofovir, lamivudine and efavirenz).
On October 1, 2019; 12 weeks after taking HAART, he complained of an enlarged lymph node in the left anterior of his neck. On physical examination we found abscesses (cold abscesses), also experienced with weight loss: 53 kg to 50 kg (5.7%) in the last month, fever (37.6 C body temperature), night sweats and cough. Increased blood CD4 T cell count after taking HAART (53 cell/muL to 650 cell/muL). Viral load: HIV-1 not detected (Figure 3).
Worsening the radiologic feature of TB (chest X-ray showed a minimal infiltrate subclavicular in the right lung) (Figure 4). In this case, the Mantoux test was positive with induration about 25 mm (Figure 5)
In this case, there were no signs and symptoms associated with other OIs, some conditions associated with drug toxicity to ATDs.
The patient has good adherence to both ATDs and antiretroviral (ARV). He always takes the drugs (ATD, ARV) every day routinely.
This case was an HIV-infected patient (WHO stage IV) and confirmed with active pulmonary TB with CD4 count 150 cell/microL and Xpert HIV-1 viral load of 5.3 log10 copies/mL. He was treated with ATD and after eight weeks of taking ATD treatment the patient was clinically stabilized or improved, but CD4 level was decreased: 150 to 53 cells/microL, Xpert HIV-1 viral load was increased to 5.8 log10 copies/mL. Twelve weeks after initiating HAART, CD4 cell level was increased rapidly (53 to 650 cells/microL) and rapid suppression of HIV viral load (from viral load of 5.8 log10 copies/mL to not detected) (Figure 6). 
Viral load (HIV RNA copies/mL) and the CD4 cell count over time in paradoxical TB-IRIS patient is shown in Figure 6.
However, the patient complained of an enlarged lymph node in the left anterior of his neck. On physical examination e abscesses were found (cold abscesses), weight loss: 53 kg to 50 kg (5.7%), fever (the patient was: 37.6 C body temperature), night sweats and cough and chest X-ray showed a minimal infiltrate.
The final conclusion of this case is paradoxical TB-IRIS in an HIV-infected patient (WHO Stage IV).
There is no consensus yet on the TB-IRIS standard treatment. This case was treated by continuing the ATD, HAART, and other symptomatic and supportive treatment. Corticosteroids at a starting dosage of 1 mg/kg body weight/day. The patient's condition gradually improves day by day. The schematic of case progress note is shown in Figure 7.