Immune reconstitution inflammatory syndrome (IRIS) is a term used to describe the paradoxical worsening of a pre-existing infection or the presentation of a previously undiagnosed condition in HIV-infected patients soon after commencement of antiretroviral therapy (ART). We report a case of a patient with HIV infection and Kaposi sarcoma, who developed bilateral chylothorax as a manifestation of IRIS, after the initiation of highly active antiretroviral therapy. Bilateral chylothorax is extremely rare and has been associated with significant morbidity and mortality. We present here the successful management with bilateral video-assisted thoracic surgery.