One of the purposes of antiretroviral therapy (ART) is to restore the immune system. However, it can sometimes lead to an\naberrant inflammatory response and paradoxical clinical worsening known as the immune reconstitution inflammatory syndrome\n(IRIS). We describe a 23-year-old male, HIV1 infected with a rapid progression phenotype, who started ART with TCD4+ of\n53 cells/mm3 (3,3%) and HIV RNA = 890000 copies/mL (6 log). Four weeks later he was admitted to the intensive care unit with\nsevere sepsis. The diagnostic pathway identified progressive multifocal leukoencephalopathy, digestive Kaposi sarcoma, and P.\naeruginosa bacteraemia. Five weeks after starting ART, TCD4+ cell count was 259 cells/mm3 (15%) and HIV RNA = 3500 copies/mL\n(4 log). He developed respiratory failure and progressed to septic shock and death. Those complications might justify the outcome\nbut its autopsy opened Pandora�s box: cerebral and cardiac toxoplasmosis was identified, as well as hemophagocytic syndrome,\nsystemic candidiasis, and Mycobacterium avium complex infection. IRIS remains a concern and eventually a barrier to ART. Male\ngender, young age, low TCD4 cell count, and high viral load are risk factors. The high prevalence of subclinical opportunistic\ndiseases highlights the need for new strategies to reduce IRIS incidence.
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