Case Presentation: A 28-year old Vietnamese man who has sex with men (MSM) with recent diagnosis of AIDS, on antiretroviral therapy (ART), presented to the hospital with 1 month of fevers associated with headaches, night sweats, anorexia, and diarrhea. He was born in Vietnam but moved to the United States 2 years prior to presentation for work. On admission, his vitals were within normal limits, except for a heart rate of 120. Physical exam was notable for clear lung fields, tenderness in the right lower quadrant, and a positive Rovsing sign. HIV viral load was 97 and CD4 count was 63. CT scan revealed diffuse pulmonary nodules in a millet-seed like distribution and a necrotic mass adjacent to the cecum. Sputum smear for acid-fast bacilli and nucleic acid amplification testing confirmed a Mycobacterium tuberculosis infection. The patient was started on piperacillin-tazobactam for the necrotic abdominal mass and isoniazid, rifampin, pyrazinamide, ethambutol, and levofloxacin for resistant mycobacterium strains. However, he continued to spike daily fevers. Cerebrospinal fluid revealed elevated protein, low glucose, and mononuclear pleocytosis, and MR brain showed leptomeningeal enhancement in the left sylvian fissure and right temporal and occipital lobes, suggestive of TB meningitis. Given his recent initiation on antiretroviral therapy, immune reconstitution inflammatory syndrome (IRIS) was also suspected. Dexamethasone was started and his symptoms abated within 24 hours.
Discussion: This was a case of an AIDS patient with disseminated TB, manifesting with miliary TB, TB meningitis, and a necrotic colonic tuberculoma, with persistent fevers despite broad antimicrobial coverage. Despite exposure to a TB-endemic region, he was not screened for TB at the time of his HIV diagnosis. Screening for latent TB is recommended at the time of initial HIV diagnosis with either tuberculin skin test or interferon gamma release assay. With a CD4 count below 100, he was at increased risk for disseminated TB and TB meningitis, which is associated with severe neurological sequelae and high mortality (up to 41%).  He was also at high risk for TB-IRIS given his disseminated TB infection, high HIV viral load at diagnosis, and low CD4 count. There are two forms of TB-IRIS: paradoxical (TB treatment before ART) and unmasking (no TB treatment before ART).  Corticosteroids are recommended in treating severe cases of unmasking TB-IRIS, as in our patient.  Use of corticosteroids also reduces short-term mortality by nearly a quarter in patients with TB meningitis, although data in HIV patients are limited. 
Conclusions: The severity and rapid progression of this patient’s TB infection illustrates the importance of TB screening in HIV patients at the time of their HIV diagnosis. AIDS patients are at greater risk for TB meningitis and TB-IRIS, which confer high morbidity and mortality. Corticosteroid administration can decrease mortality in both of these conditions.