A 22 year-old African immigrant male came to the emergency room reporting fever, chills, sweating at night, cough, pain in the chest, blood in the sputum and weight loss. His medical history is significant for AIDS and cryptococcal meningitis. He was diagnosed with HIV four years ago. Two months ago he was treated in this hospital for cryptococcal meningitis with IV infusions of amphotericin B and flucytosine. He improved well and was discharged in good condition. At the time of his discharge, his CD4+ cell count was 84 cells per microliter and HIV-1 viral load was 316232 RNA copies/mL. Two weeks after his discharge, he was started on highly active antiretroviral therapy (HAART) for HIV. He reports that he felt ‘great’ since his discharge from the hospital till this new sickness came up. His vital signs were, Temp = 101.2 F, O2 saturation 95%, BP 90/60 mm Hg, RR 17/minute, Pulse 94/minute. Some of the laboratory results are as follows: CD4 count is 1200 cells/mm3 HIV-1 viral load of 4800 RNA copies/mL Nucleic Acid Amplification Test is positive for mycobacterium tuberculosis in the sputum. Chest X ray showed bilateral lower lung zone infiltrates and mediastinal lymphadenopathy. On hearing these reports, the patient stated that while there are lots of people with tuberculosis in his native Senegal, he never thought he would get it. Which of the following was a risk factor for immune reconstitution inflammatory syndrome in this patient?
