TB treatment failure, drug hypersensitivity and other opportunistic infections and malignancies need to be excluded.

  •  Corticosteroids 

The management of IRIS may require moderate-to-highdose corticosteroids, sometimes for prolonged periods, in order to control symptoms. Prednisone or methylprednisolone has been used at a dose of 1–1.5 mg/kg, which was gradually reduced after 1–2 weeks. Patients who have been on rifampicin for 2 weeks or more will have increased liver metabolism of corticosteroids, such that the corticosteroid is effectively reduced by 33–50%. Patients may require steroids for prolonged periods of time and IRIS may recur when the dose is reduced, necessitating higher doses.

Physicians should be aware of the metabolic side effects and potential for serious infections, for instance cytomegalovirus retinitis with high-dose corticosteroids.

Other treatment options

Recurrent needle aspiration of nodes or abscesses is appropriate if they become tense and/or inflamed. This can prevent spontaneous rupture which may lead to longterm sinus formation and scarring. Other treatments have as yet little evidence supporting their use. Nonsteroidal anti-inflammatory agents aregenerally not helpful. Temporary discontinuation of antiretroviral therapy has also been advocated but can cause precipitous falls in CD4 cell counts. Leukotriene overactivity has been implicated in IRIS, and montelukast can be considered as an alternative to steroids, but may need to be continued for a long period. The efficacies of other therapies such as interleukin-2, granulocyte–macrophage colony-stimulating factor and hydroxychloroquine are as yet unproven.