Therefore, TNF antagonists impair the host immune response against infections such as tuberculosis. While the patient is taking TNF antagonists, these infections may remain latent and asymptomatic. However, when these medications are discontinued, there may be an associated pro-inflammatory response causing the infection to be uncovered. In cryptococcal meningitis IRIS is particularly problematic in cryptococcal meningitis as IRIS is fairly common and can be fatal. IRIS has been described in immunocompetent hosts who have meningitis caused by Cryptococcus gattii and Cryptococcus neoformans var. grubii, environmental fungi which often affect immunocompetent hosts. Several weeks or even months into appropriate treatment, there is a sudden onset deterioration with worsening meningitis symptoms and progression or development of new neurological symptoms. Magnetic resonance imaging shows increase in the size of brain lesions, and CSF abnormalities (white cell count, protein, glucose) increase. CSF culture is typically sterile, and there is no increase in CSF cryptococcal antigen titer. The increasing inflammation can cause brain injury or be fatal. The general mechanism behind IRIS is increased inflammation as the recovering immune system recognizes the antigens of the fungus as immunosuppression is reversed. Cryptococcal IRIS has three phases: before HAART, with a paucity of cerebrospinal fluid (CSF) inflammation and defects in antigen clearance; during initial HAART immune recovery, with pro-inflammatory signaling by antigen-presenting cells without an effector response; and at IRIS, a cytokine storm with a predominant type-1 helper T-cell interferon-gamma response. Three clinical predictors of cryptococcal-related paradoxical IRIS risk include: lack of initial CSF pleocytosis (i.e. low CSF white blood cell count); elevated C-reactive protein; failure to sterilize the CSF before immune recovery. IRIS may be the cause of paradoxically worse outcomes for cryptococcal meningitis in immunocompetent compared with immunocompromised hosts, in whom Cryptococcus neoformans is the usual pathogen. Treatment with systemic corticosteroids during IRIS may be beneficial in preventing death or progressive neurological deterioration. Steroids given to persons with anti-fungal treatment failure / cryptococcal relapse (in whom CSF cultures are not sterile) can be a fatal iatrogenic error. Signs and symptoms The clinical presentation of IRIS is variable and typically depends on the underlying OI. Common features that may be present include clinical worsening after starting ART and localized tissue inflammation. A systemic inflammatory response may or may not be present. The majority of IRIS cases occur within 4 to 8 weeks of ART initiation or change. However, there have been reported cases from 3 days