AN OUTSTANDING QUESTION, which refers to IRIS --- Paradoxical deterioration in clinical status after ART initiation despite improved immune function; due to inflammatory response against infectious antigen, which may or may not have been Dx’d at initiation of ART -- & in this case, Mycobacterium Tb. Immune Reconstitution Inflammatory Syndrome[IRIS] typically occurs in pts with low initial CD4 (usually 25%) of paradoxical worsening in pts with active TB after initiation of ART, overall mortality reduced in pts with CD4 < 100 treated with combined ART & ATT. GENERALLY, we use Anti-inflammatory therapy (NSAIDs FIRST, and/or corticosteroids) to mitigate symptoms associated with IRIS. Response to corticosteroids typically rapid (1-2 mg/kg prednisone or equivalent for 1-2 wks --- GENERALLY, prednisone 20-40 mg/d for 2 wks with slow taper. In pts with active TB not on ART, ART should be initiated during continuation phase of TB therapy. HOWEVER, In THIS CASE, very early initiation of ART (within 4 ks of initiation of TB therapy) indicated in pts with CD4 < 50, given the improved mortality. Therefore, I would choose [C] ■■REFERENCES: ▪Abdool Karim SS et al: Timing of initiation of antiretroviral drugs during tuberculosis therapy. N Engl J Med 362:697, 2010 [open-label, randomized, controlled trial with 642 patients with TB/HIV co-infection to start ART either during tuberculosis therapy or after the completion of TB treatment. Mortality was LOWER in patients initiating ART during TB therapy in all CD4 strata.

c

It’s Kiesselbach’s plexus/Kiesselbach’s triangle

It is a circular junction on the inside of medial wall of the nose where many artries come together . Its the most common area for Epistaxis

same