Double trouble: Concomitant unmasking and paradoxical immune reconstitution inflammatory syndrome in a patient with newly diagnosed HIV

Immune reconstitution inflammatory syndrome (IRIS) is a complication encountered in patients with HIV due to immune function recovery following the initiation of antiretroviral therapy. IRIS can be divided into two forms: paradoxical (recurrence of clinical signs of a previously treated opportunistic infection) and unmasking (uncovering of a previously undiagnosed and asymptomatic infection). We present the rare case of a 48-year-old man diagnosed with AIDS after presenting with cryptococcal meningitis who, shortly after initiation of ART, developed both unmasking IRIS due to Mycobacterium avium complex (MAC), and subsequently paradoxical IRIS to his prior cryptococcal meningitis infection. To our knowledge, cases in the medical literature describing “double IRIS” remain scarce.