Herpes zoster as an immune reconstitution disease after initiation of combination antiretroviral therapy in patients with human immunodeficiency virus type-1 infection

HIV and an Ageing Population-What Are the Medical, Psychosocial, and Palliative Care Challenges in Healthcare Provisions

The continuing increase in patient numbers and improvement in healthcare provisions of HIV services in the UK, alongside the effectiveness of combined antiretroviral therapy (cART), has resulted in increasing numbers of the ageing population among people living with HIV (PLWH). It is expected that geriatricians will need to deal with many older people living with HIV (OPLWH) as life expectancy increases. Therefore, geriatric syndromes in OPLWH will be similar to the normal population, such as falls, cognitive decline, frailty, dementia, hypertension, diabetes and polypharmacy. The increase in the long-term use of cART, diabetes, dyslipidaemia and hypertension may lead to high prevalence of cardiovascular disease (CVD). The treatment of such conditions may lead to polypharmacy and may increase the risk of cART drug-drug interactions. In addition, the risk of developing infection and cancer is high. OPLWH may develop an early onset of low bone mineral density (BMD), osteoporosis and fractures. In this review, we have also provided potential psychosocial aspects of an ageing population with HIV, addressing issues such as depression, stigma, isolation and the need for comprehensive medical and psychosocial care through an interdisciplinary team in a hospital or community setting. OPLWH have a relatively high burden of physical, psychological, and spiritual needs and social difficulties, which require palliative care. The holistic type of palliative care that will improve physical, emotional and psychological wellbeing is discussed in this review.

Visceral Leishmaniasis and Herpes Zoster as a Component of Syndrome of Immune Reconstitution Inflammatory Syndrome in an HIV-Positive Patient

Immune reconstitution syndrome (IRIS) is a state of unusual hyperinflammatory response against latent infections which occurs after CD4 cell count improvement and as a consequence of immune response once highly active antiretroviral therapy for HIV is introduced. Leishmania parasites and varicella zoster virus (VZV) may be a manifestation of IRIS, but few data exist in literature in particular regarding Leishmania parasites. Case Presentation. A 47-year-old man was admitted to our hospital with fever. He was diagnosed with HIV infection and was a late presenter according to CD4+ count of 98 cells/mm³/9.5% and baseline illness (chronic diarrhea, weight loss, and oral candidiasis). The patient started highly active antiretroviral therapy (abacavir plus lamivudine plus efavirenz). Clinical symptoms improved and CD4+ increased to 22%, 374 cells/mm³. After 88 days, he presented with a 17-day history of high fever, sweat, fatigue, further weight loss, and lethargy. According to clinical image findings and hematochemical parameters, the patient was diagnosed with visceral leishmaniasis. He improved under treatment with liposomal amphotericin B. He presented again, 105 days after with disseminated herpes zoster infection. CD4+ count was 28.5%, 455 cell/mm³. The patient started treatment with acyclovir for 10 days. Four weeks later, he had no skin elements. At present, the patient continues HAART and is under regular monitoring. Conclusions. Early diagnosis of IRIS-associated diseases and treatment were fundamental in the patient's prognosis. Our patient presented with two different components of IRIS in two different time frames, confirming IRIS to be a broad-spectrum disease, heterogeneous and unique for each patient. A close monitoring during ART initiation, in particular in late presenters, is important in preventing IRIS. In case of IRIS development, a detailed investigation of rare associated diseases not only common ones is of great importance for the management and the prognosis of these patients.

Development of a Model for Predicting the Effectiveness of Pulsed Radiofrequency on Zoster-Associated Pain

Introduction

Zoster-associated pain (ZAP), which may cause anxiety, depression, and sleep disorders and reduce quality of life, is often refractory to current standard treatments. Studies have shown that pulsed radiofrequency (PRF) can alleviate ZAP and reduce the incidence of postherpetic neuralgia (PHN). This study aimed to explore the clinical characteristics associated with PRF responsiveness, develop a model for identifying risk factors of inadequate PRF management, and help clinicians make better decisions.

Methods

Patients who underwent PRF for ZAP between January 2017 and October 2020 in our hospital were included in this study. Patients were evaluated using the numerical rating scale (NRS), Insomnia Severity Index, Patient Health Questionnaire-9, and 36-Item Short Form Health Survey (SF-36) before and 3 months after the procedure. Patient demographic data and blood test results were also collected. We defined the effectiveness of PRF for ZAP as relief of > 50% in NRS scores compared to pre-PRF. Least absolute shrinkage and selection operator (LASSO) regression analyses were subsequently performed to identify factors related to the therapeutic effect of PRF in patients with ZAP. The performance of the prediction model was assessed by the area under the receiver operating characteristic curve (AUC).

Results

The effectiveness of PRF in patients with ZAP was 69.6% (total 313 patients) after 3 months. LASSO regression analysis extracted the seven most powerful features in the developed prediction model: sex, stage of herpes zoster (HZ), pregabalin dose, bodily pain indicators of SF-36, lymphocyte count, and low-density lipoprotein cholesterol (LDLC) and complement C4 in peripheral blood. Model = 1.586 + 0.148 × lymphocyte + (−0.001) × bodily pain indicators of SF-36 + (−0.001) × pregabalin dose + 0.028 × LDLC + 0.001 × C4 + (−0.508) × sex + (−0.128) × stage of HZ. We generated the ROC curve for the prediction model, and the final AUC was 0.701. The sensitivity, specificity, and overall accuracy of the model were 90%, 33%, and 73%, respectively.

Conclusions

Seven factors were significantly associated with poor PRF outcome: male sex, advanced stage of HZ, higher pregabalin dose, higher bodily pain indicators of SF-36, and lower lymphocyte count, LDLC, and complement C4 in the peripheral blood. PRF should be applied to patients with ZAP as early as possible to achieve satisfactory outcomes.

Immune recovery folliculitis: Case reports in HIV naïve and experienced patients

Immune recovery folliculitis (IRF) is defined as the development of an inflammatory disorder of the facial pilo-sebaceous unit due to the immune reconstitution inflammatory syndrome (IRIS). Skin lesions can be related to an immune response against skin saprophyte bacteria (e.g. Demodex folliculorum, Cutibacterium acnes). The rapid reconstitution of T lymphocyte, with a CD8+ predominance, is considered a key pathogenic factor for this phenomenon. IRF is clinically similar to acne vulgaris and can be challenging to treat. Patients with facial pustules can experience social discomfort. Here we report two cases of IRF diagnosed at the human immunodeficiency virus (HIV) clinic of the National Institute of Infectious Diseases L. Spallanzani, in Rome, Italy. The first case occurred in an antiretroviral therapy (ART)-experienced patient, after a treatment simplification; the second one was registered in an ART-naïve patient, diagnosed with acute HIV infection shortly, after ART initiation. To date, an IRF secondary to an ART switch, has not been described yet. IRF should be ruled out and considered in differential diagnosis from antiretroviral drug-related skin effects.

A case of paraplegia due to asymptomatic varicella-zoster virus infection in AIDS patient unexpectedly diagnosed by CSF metagenomic next-generation sequencing

BACKGROUND

Varicella-zoster virus (VZV) infection may induce central nervous system complications in HIV/AIDS patients. However, it is rare to have paraplegia caused by VZV infection but no herpes zoster clinically. Asymptomatic VZV infection in HIV/AIDS patient increased the difficulty of diagnosis.

CASE PRESENTATION

We reported a 41-year-old male AIDS patient with rare asymptomatic VZV infection-induced paraplegia after his anti-retroviral therapy initiation. MRI of the spinal cord showed the morphology of the thoracic spinal cord was irregular and locally inflated. The patient was confirmed as VZV induced thoracic myelomyelitis by using the cerebrospinal fluid for metagenomic next-generation sequencing (mNGS).

CONCLUSIONS

mNGS may contribute to disease diagnosis for asymptomatic VZV infection-induced myelitis.

Dermatological Opportunistic Infections in HIV Seropositive Patients: An Observational Study

Background and objective

In developing countries, the dermatological manifestation of the human immunodeficiency virus (HIV) has a high prevalence. Apart from the systemic infection that ensues HIV, skin manifestations form a major part of the disease burden. They can present with atypical forms, and necessary tools for diagnosis may not be available in rural and remote parts of the country. Hence, they can stay misdiagnosed or undiagnosed, contributing to the morbidity of the patients. We attempted to enumerate the dermatologic opportunistic infections (OIs) in Rajkot city, Gujarat, India, in order to disseminate knowledge regarding the same. 

Material and methods

It is a retrospective observational study. A total of 253 patients under treatment for HIV/acquired immunodeficiency syndrome (AIDS) at the ART Center (anti-retroviral therapy center) from 2011 to 2019 were included. The data recorded in the registry during the above-mentioned period were utilized in the study. The diagnoses of OIs were made clinically by multiple health care providers experienced in the field.

Result

Two hundred twenty-seven (227) of 253 (89.72%) of the patients had some form of dermatologic OI during the course of their treatment. Overall, fungal infections (33.03%) were most common, followed by bacterial infections (28.18%) and viral (14.55%) infections. Among the non-infectious causes, cheilitis/angular stomatitis topped the list. Among the STDs, herpes was the most common skin manifestation seen with a 10.57% prevalence. The CD4+ cell count for fungal infection ranged from 353-467 and was seen in stage 2 of the disease course. Bacterial infections were seen mainly during the early and middle stages of the disease while viral infections were most prevalent in stage 2 of the disease.

Conclusion

Skin manifestations can be useful clinical predictors of the disease stage, especially in resource-limited settings and in developing countries. They can present with unusual and atypical forms. Hence, knowledge about the prevalence of these OIs in a particular geographical area can be very useful for physicians in treating them and decreasing the disease burden.

Incidence of Herpes Zoster in HIV-Infected Patients Undergoing Antiretroviral Therapy: A Systematic Review and Meta-analysis

The incidence of herpes zoster (HZ) in patients infected with HIV is higher than that of the general population. However, the incidence of HZ in HIV patients receiving antiretroviral therapy (ART) remains unclear. This meta-analysis aimed to estimate the pooled incidence rate and risk factors for HZ in the post-ART era. We identified studies assessing the incidence of HZ in the post-ART era between 1 January 2000 and 28 February 2021, from four databases. Pooled risk ratios were calculated from 11 articles using a random-effects model. The heterogeneity of the included trials was evaluated by visually inspecting funnel plots, performing random-effects meta-regression and using I² statistics. Of the 2111 studies screened, we identified 11 studies that were eligible for final inclusion in the systematic review and 8 studies that were eligible for a meta-analysis. The pooled incidence of HZ in the post-ART era (after the introduction of ART in 1997) was 2.30 (95% confidence interval (CI): 1.56-3.05) per 100 person years (PYs). The risks of incidence of HZ among people living with HIV included male sex (AOR: 4.35 (95% CI: 054-2.41)), men who have sex with men (AOR: 1.21 (95% CI: -0.76-1.13)), CD4 count < 200 cells/μL (AOR: 11.59 (95% CI: 0.53-4.38)) and not receiving ART (AOR: 2.89 (95% CI: -0.44-2.56)). The incidence of HZ is substantially lower among HIV infected patients receiving ART than those not receiving ART. Initiating ART immediately after diagnosis to treat all HIV-positive individuals is crucial to minimize the disease burden of HZ.

Primary and Acquired Immunodeficiencies Associated with Severe Varicella-Zoster Infections

BACKGROUND

While most cases of varicella or zoster are self-limited, patients with certain immune deficiencies may develop severe or life-threatening disease.

METHODS

We studied a patient with varicella-zoster virus (VZV) CNS vasculopathy and as part of the evaluation, tested his plasma for antibodies to cytokines. We reviewed the literature for cases of varicella or zoster associated with primary and acquired immunodeficiencies.

RESULTS

We found that a patient with VZV CNS vasculopathy had antibody that neutralized interferon (IFN)-α, but not IFN-γ. The patient's plasma blocked phosphorylation in response to stimulation with IFN-α in healthy control peripheral blood mononuclear cells. In addition to acquired immunodeficiencies like HIV or autoantibodies to IFN, variants in specific genes have been associated with severe varicella and/or zoster. While these genes encode proteins with very different activities, many affect IFN signaling pathways, either those that sense double-stranded RNA or cytoplasmic DNA that trigger IFN production, or those involved in activation of IFN stimulated genes in response to binding of IFN with its receptor.

CONCLUSIONS

Immune deficiencies highlight the critical role of IFN in control of VZV infections and suggest new approaches for treatment of VZV infection in patients with certain immune deficiencies.

Types and prevalence of HIV-related opportunistic infections/conditions among HIV-positive patients attending Kenyatta National Hospital in Nairobi, Kenya

Background

Although antiretroviral therapy (ART) has resulted in significant decrease in opportunistic infections (OIs), OIs continue to cause significant morbidity and mortality among HIV patients.

Objective

To determine the prevalence and types of HIV/AIDS-related OIs among patients attending Kenyatta National Hospital (KNH) in Nairobi, Kenya.

Methods

A cross-sectional study was conducted from May to August 2010 among patients ≥19 years. An interviewer-administered questionnaire was used to collect data on socio-demographic factors, HIV and OIs. CD4 data were extracted from clinical records.

Results

Most patients (72%) had lived with HIV for ≤ 5 years and 78.8% had an OI. The 3 most common OIs were TB (35%), Herpes Zoster (HZ; 15.4%) and oral thrush (OT; 8%). Years of HIV infection significantly predicted TB (p=0.01). Patients with CD4 ≤ 349 were almost twice as likely to have TB, than those with CD4 ≥500. Type of occupation predicted OT (p=0.04) with skilled workers less likely to have OT. Patients with primary/vocational/technical education were >3 times more likely to have HZ than those with tertiary education.

Conclusion

Due to the complex management of HIV and its associated OIs, appropriate implementation of the recommended guidelines for care and prevention among patients at KNH is important.

Correlation between Galectin-3 and Early Herpes Zoster Neuralgia and Postherpetic Neuralgia: A Retrospective Clinical Observation

This study aims to explore the value of serum galectin-3 in patients with herpes zoster neuralgia (HZN) and postherpetic neuralgia (PHN) and other factors influencing HZN and PHN occurrence. Samples from forty patients with herpes zoster neuralgia (HZN) (Group H), 40 patients with nonherpes zoster neuralgia (Group N), and 20 cases of health check-up were collected. Patients were divided into PHN group (Group A) and non-PHN group (Group B) according to the occurrence of PHN in Group H. Galectin-3, T-lymphocyte subsets, and IL-6 were recorded in all patients. The changes of galectin-3 in patients with early HZN and PHN were analyzed by single-factor analysis and multifactor analysis. The age (P=0.012) and NRS scores (P < 0.001) of PHN patients were significantly higher than those of non-PHN patients and other neuralgia patients. The ratio of CD3+ (F = 80.336, P < 0.001), CD4+ (F = 12.459, P < 0.001) lymphocyte subsets, and CD4+/CD8+ (F = 15.311, P < 0.001) decreased significantly in PHN patients. The level of blood IL-6 (F = 139.446, P < 0.001) in PHN patients was significantly increased. Serum galectin-3 was significantly higher in HZN patients than in PHN patients (P < 0.05); IL-6 (OR = 10.002, 95% CI: 3.313-30.196, P < 0.001) and galectin-3 (OR = 3.719, 95% CI: 1.261-10.966, P=0.017) were the risk factors for HZN; galectin-3 (OR = 17.646, 95% CI: 2.795-111.428, P=0.002) was also the risk factor for PHN. ROC curve analysis also showed that serum galectin-3 was a better predictor of poor prognosis (AUC = 0.934, P < 0.001). Therefore, as an independent risk factor of HZN and PHN, serum galectin-3 may be used as a new biochemical marker in clinical practice.

HIV-Related Skin Disease in the Era of Antiretroviral Therapy: Recognition and Management

Antiretroviral therapy (ART) has revolutionized the treatment and prognosis of people living with HIV (PLHIV). With increased survival and improved overall health, PLHIV are experiencing dermatologic issues both specific to HIV and common to the general population. In this new era of ART, it is crucial for dermatologists to have a strong understanding of the broad range of cutaneous disease and treatment options in this unique population. In this review, we outline the most common skin diseases in PLHIV, including HIV-associated malignancies, inflammatory conditions, and infections, and focus on the role of ART in altering epidemiology, clinical features, diagnosis, and treatment of cutaneous conditions.

Increase in HSV shedding at initiation of antiretroviral therapy and decrease in shedding over time on antiretroviral therapy in HIV and HSV-2 infected persons

OBJECTIVES

HIV-infected persons with chronic herpesvirus infections may experience paradoxical worsening after initiation of antiretroviral therapy (ART), but the impact of longer term ART is unclear. We evaluated the relationships between genital herpes simplex virus (HSV) shedding and ART initiation and time on therapy in HIV and HSV-2-infected persons.

DESIGN

Prospective observational study.

METHODS

Rates of HSV shedding in 45 HIV and HSV-2-infected persons on or off ART were prospectively followed over up to three, noncontiguous, 60-day periods, during which participants performed daily genital swabs for HSV detection by real-time HSV DNA PCR and reported symptoms. Initiation or discontinuation of ART was at the discretion of participants' healthcare providers.

RESULTS

In all, 6425 daily genital swabs were obtained from 45 persons (38 men and seven women) during 105 swabbing sessions. During the three sessions, 67, 74, and 92% of persons were on ART. HSV was detected on 26.5% of days in men and 22.3% of days in women. The overall rates of genital HSV shedding were 19.4% of days in persons not on ART, 30.2% in persons within 90 days of ART initiation, and 23.3% in persons on ART for longer than 90 days. After initiation of ART, HSV shedding decreased by 2% per month, or 23% per year (RR 0.98/month on ART; P = 0.0003 in adjusted analysis). This finding was consistent after including consideration of HIV viral load and CD4 cell count.

CONCLUSIONS

HSV shedding increased significantly shortly after ART initiation, but decreased with time on prolonged ART.

Understanding mechanisms underlying the pathology of immune reconstitution inflammatory syndrome (IRIS) by using animal models

Purpose of Review

Despite the increasing number of clinical reports on immune reconstitution inflammatory syndrome (IRIS), mechanistic understanding of IRIS is still largely limited. The main focus of this review is to summarize animal studies, which were performed to better understand the cellular and molecular mechanisms underlying the pathology of IRIS.

Recent Findings

Three IRIS animal models have been reported. They are Mycobacterial IRIS (M-IRIS), cryptococcal IRIS (C-IRIS) and Pneumocystis-IRIS. M-IRIS animal model suggested that, rather than lymphopenia itself, the failure to clear the pathogen by T cells results in excessive priming of the innate immune system. If this happens before T cell reconstitution, hosts likely suffer IRIS upon T cell reconstitution. Interestingly, T cells specific to self-antigens, not only pathogen-specific, could drive IRIS as well.

Summary

The mechanism to develop IRIS is quite complicated, including multiple layers of host immune responses; the innate immune system that detects pathogens and prime host immunity, and the adaptive immune system that is reconstituted but hyper-activated particularly through CD4⁺ T cells. Animal models of IRIS, although there are still small numbers of studies available, have already provided significant insights on the mechanistic understanding of IRIS.

Immune reconstitution inflammatory syndrome in HIV infection: taking the bad with the good

In this review, we will describe the immunopathogies of immune reconstitution inflammatory syndrome, IRIS. IRIS occurs in a small subset of HIV patient, initiating combination antiretroviral therapy (ART), where immune reconstitution becomes dysregulated, resulting in an overly robust antigen-specific inflammatory reaction. We will discuss IRIS in terms of the associated coinfections: mycobacteria, cryptococci, and viruses.

Herpes virus reactivation after initiation of interferon-free antiviral agents in HIV-HCV-coinfected subjects: a new immune restoration disease?

We report four HCV-HIV-coinfected patients who developed herpes zoster or muco-cutaneous herpes virus disease shortly after starting interferon-free antiviral treatment for HCV. We suggest that in our patients the prompt clearance of HCV following direct-acting antivirals leads to a paradoxical effect on the innate and adaptive immune system mediating the reactivation of herpetic infection.

Incidence and risk factors of herpes zoster in human immunodeficiency virus-positive patients initiating combination antiretroviral therapy in Taiwan

BACKGROUND/PURPOSE

To obtain current epidemiological data for better vaccination policies, this study aimed to assess the incidence and risk factors of herpes zoster in human immunodeficiency virus (HIV)-positive patients initiating combination antiretroviral therapy (cART) in Taiwan.

METHODS

Between June, 2012 and May, 2015, we prospectively identified zoster cases in HIV-positive patients initiating cART. Clinical information was collected on demographics, prior zoster, plasma HIV-1 RNA load (PVL), and CD4 count at baseline and during follow up. A case-control study by 1:2 matched pairs was used to identify the risk factors for zoster development.

RESULTS

During the 3-year study period, 826 patients with a mean age of 32.9 years were included, and 7.7% had prior zoster. The mean baseline CD4 count and PVL were 286 cells/μL and 4.90 log₁₀ copies/mL, respectively. Fifty-four (6.5%) patients developed zoster after initiation of cART, with 43 episodes (79.6%) occurring within 1 year of cART initiation, which corresponded to an overall incidence rate of 3.61/100 person-years. The multivariate analysis revealed that prior zoster (adjusted odds ratio = 3.143; 95% confidence interval, 1.385-7.133) and baseline CD4 count < 200 cells/μL (adjusted odds ratio = 2.034; 95% confidence interval, 1.020-4.057) were independent risk factors for zoster in HIV-positive patients initiating cART. In case-control study, prior zoster and baseline PVL > 5 log₁₀ copies/mL were risk factors for zoster development after cART initiation in multivariate analysis.

CONCLUSIONS

Herpes zoster occurred in 6.5% of HIV-positive Taiwanese patients after initiation of cART, which was associated with prior zoster and baseline CD4 count < 200 cells/μL or baseline PVL > 5 log₁₀ copies/mL.

The 2015 Clinical Guidelines for the Treatment and Prevention of Opportunistic Infections in HIV-Infected Koreans: Guidelines for Opportunistic Infections

The Committee for Clinical Guidelines for the Treatment and Prevention of Opportunistic Infections of the Korean Society for AIDS was founded in 2011. The first edition of the Korean guidelines was published in 2012. The guideline recommendations contain important information for physicians working with human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) in the clinical field. It has become necessary to revise the guidelines due to new data in this field. These guidelines aim to provide up-to-date, comprehensive information regarding the treatment and prevention of opportunistic infections in HIV-infected Koreans. These guidelines deal with several common opportunistic infections, including pneumocystis pneumonia, tuberculosis, cryptococcal meningitis, etc. A brief summary of the revised guidelines is provided below. Recommendations are rated using the same system used in the previous guidelines.

Incidence of herpes zoster in HIV-infected adults in the combined antiretroviral therapy era: results from the FHDH-ANRS CO4 cohort

BACKGROUND

Recent studies have shown a decrease in the incidence of herpes zoster (HZ) among human immunodeficiency virus (HIV)-infected patients since the combined antiretroviral therapy (cART) era, but more data are needed on a possible increase in the risk early after cART initiation.

METHODS

We studied HZ incidence and risk factors among patients followed in the French Hospital Database on HIV (FHDH) between 1992 and 2011. Standardized incidence ratios (SIRs) were used for comparison with the general population between 2005 and 2008. The risk of HZ following cART initiation (0-5 and ≥6 months) was studied with Poisson regression models.

RESULTS

A total of 7167 cases of incident HZ were diagnosed among 91 044 individuals (583 125 person-years [PY]). The incidence declined significantly, from 2955 per 100 000 PY in 1992-1996 to 628 per 100 000 PY in 2009-2011. This decline was mainly explained by cART (relative risk [RR], 0.60; 95% confidence interval {CI}, .57-.64). The risk of HZ was associated with low CD4 cell counts, high HIV RNA levels, low CD4/CD8 ratios, and prior AIDS. Compared to the general population, the risk of HZ was higher in HIV-infected patients (overall SIR, 2.7; 95% CI, 2.6-2.9), particularly those aged 15-44 years (SIR, 4-6). In ART-naive patients, a moderate increase in the HZ risk was observed during the first 6 months of cART, with a peak at 3 months (RR, 1.47; 95% CI, 1.26-1.73), a finding that disappeared after adjustment for the current CD4 cell count (RR, 1.03; 95% CI, .81-1.32).

CONCLUSIONS

The risk of HZ has declined markedly among HIV-infected patients in the cART era, but remains 3 times higher than in the general population. The risk increases moderately during the first 6 months of cART.

Effects of highly active antiretroviral therapy and its adherence on herpes zoster incidence: a longitudinal cohort study

BACKGROUND

Herpes zoster (HZ) is common among HIV-infected individuals, but the impacts of highly active antiretroviral therapy (HAART) and HAART adherence on HZ risk have not been well studied.

METHODS

The effects of HAART and HAART adherence on HZ incidence were evaluated by comparing HIV-infected women on HAART (HAART use group) with the HIV-infected women remaining HAART naïve (HAART naïve group) in the Women's Interagency HIV Study (WIHS). A 1:1 matching with propensity score for predicting HAART initiation was conducted to balance background covariates at index visit, including HIV disease stage. Kaplan-Meier method was used to compare the risk of HZ development between the matched pairs. Cox proportional hazard models were used to assess the effects of HAART and HAART adherence on HZ incidence.

RESULTS

Through propensity score matching, 389 pairs of participants were identified and they contributed 3,909 person years after matching. The background covariates were similar between the matched pairs at the index visit. The participants had a mean age around 39 years old, and about 61% of them were Black and 22% were Latina. No significant difference in HZ risk was observed between the HAART use group and the HAART naïve group during the first year of follow-up in any analyses. In the univariate analysis, the HAART use group had marginally lower HZ risk (Hazard Ratio (HR): 0.72; 95% Confidence Interval (CI): 0.48-1.1) over the entire follow-up period. However, women with a HAART adherence level of ≥95% had significantly lower HZ risk (HR: 0.54; 95% CI: 0.31, 0.94) compared to the HAART naïve women. The association remained significant after adjusting for quality of life score and acyclovir use, but it attenuated and was no longer statistically significant after adjusting for an intermediate variable, either CD4+ T cell counts or HIV viral load.

CONCLUSIONS

Among adult women, we observed a significant preventive effect of long-term HAART use on HZ incidence when a HAART adherence level of ≥95% was attained, and this effect was mediated through reduction of HIV viral load and improvement of CD4+ T cell counts.

Predictive factors of herpes zoster HIV-infected patients: another adverse effect of crack cocaine

A retrospective cohort study was conducted on 1541 HIV-infected patients to determine variables associated with the incidence of herpes zoster. A single failure Cox model showed that herpes zoster incidence increased following the first 6 months of antiretroviral treatment adjusted hazard ratio (AHR)=5 (95%CI=2.6-9.2), P<0.001; in the >60 years age group AHR=2 (95%CI=1-4), P=0.04; in patients in the top CD8 quartile AHR=2.1 (95%CI=1.3-3.6), P<0.001; and in patients previously reported to use crack cocaine AHR=5.9, (95%CI=1.4-25), P=0.02. Herpes zoster incidence increased in patients with CD4 counts<500 per mm³ and gradually declined since 1992-1996, with AHR=0.3 (95%CI=0.2-0.5), P<0.001 for the 1997-2002 period and AHR=0.24 (95%CI=0.14-0.4), P<0.001 for the 2002-2008 period. Contrary to what has been described elsewhere, there was no specific effect of protease inhibitors on herpes zoster incidence. The present study is the first to suggest that crack cocaine is associated with an increased incidence of herpes zoster. The neurological or immunological effects of crack are discussed.

Ocular complications and loss of vision due to herpes zoster ophthalmicus in patients with HIV infection and a comparison with HIV-negative patients

The aim of the work is to describe the occurrence of ocular complications and loss of vision due to herpes zoster ophthalmicus (HZO) in HIV-positive patients who received early antiviral therapy for HZO. This is a post hoc analysis of prospectively collected data. Twenty-four HIV-positive patients with HZO were included in this report; male to female ratio was 3.8:1; mean age was 33.5 (±14.9) years. The visual outcome was good, with 14/24 patients having 6/6 vision; severe vision loss (≤6/60) occurred in only 2/24. There was no statistical difference in the visual outcome between the HIV-positive and -negative patients ( P = 0.69), although severe vision loss was more likely in HIV-infected patients. The ocular complications of HZO in HIV-infected patients were: reduced corneal sensation (17/24), corneal epithelial lesions (14/24), uveitis (12/24), elevated intraocular pressure (10/24) and extra-ocular muscle palsy (3/24). The severity of rash was similar in the two groups but multidermatomal rash occurred only in HIV-infected patients (4/24). There was no difference in the occurrence of ocular complications of HZO between HIV-positive and HIV-negative patients. HZO associated ocular complications and visual loss is low in HIV-infected patients if treated with HZO antiviral therapy and was comparable with HIV-negative patients. Early institution of HZO antiviral therapy is recommended to reduce ocular complication and vision loss.

Decreasing incidence of herpes zoster in the highly active antiretroviral therapy era

We evaluated the effect of highly active antiretroviral therapy (HAART) on the incidence of herpes zoster (HZ) in human immunodeficiency virus (HIV)-infected subjects. The annual incidence of HZ per 100 person-years decreased significantly from 6.3 episodes in 1987 to 1.0 episode in 2011, probably reflecting improved immune function.

Herpes zoster among persons living with HIV in the current antiretroviral therapy era

BACKGROUND

Previously, herpes zoster (HZ) was found to occur at a higher rate in the HIV population than the general population. However, there are limited data about the incidence, risk factors, and clinical outcomes of HZ in the current antiretroviral therapy (ART) era.

METHODS

We identified HZ episodes in an urban HIV clinic cohort between 2002 and 2009. Three controls were matched to each case, and conditional logistic regression was used to assess for risk factors associated with incident HZ cases. Logistic regression was used to assess for factors associated with complicated HZ.

RESULTS

One hundred eighty-three new HZ cases were identified in 4353 patients with 19,752 person-years (PY) of follow-up--an incidence rate 9.3/1000 PY. Cases were majority men (62%) and African American (75%), with a mean age of 39 years (interquartile range, 32-44 years). Fifty patients (28%) had complicated HZ with 12% developing postherpetic neuralgia. In multivariate regression, factors associated with the increased risk of HZ were having started ART within 90 days of the episode [adjusted odds ratio (AOR), 4.02; 95% confidence interval (CI), 1.31 to 12.41], having a viral load of >400 copies per milliliter (AOR, 1.49; 95% CI, 1.00 to 2.24), and having a CD4 <350 cells per cubic millimeter (AOR, 2.46; 95% CI, 1.42 to 4.23) or 350 to 500 cells per cubic millimeter (AOR, 2.02; 95% CI, 1.14 to 3.57) as compared with CD4 >500 cells per cubic millimeter.

CONCLUSIONS

The incidence of HZ is lower than previously reported in HIV cohorts but remains higher than the general population. Over one fourth of patients developed complicated HZ, which is remarkable given the young age of our population. Risk factors for HZ include markers of poor immune function, suggesting that appropriate ART may reduce the burden of HZ in this population.

Pathogenesis of the immune reconstitution inflammatory syndrome in HIV-infected patients

PURPOSE OF REVIEW

The immune reconstitution inflammatory syndrome (IRIS) is an important clinical complication in HIV-infected patients initiating antiretroviral therapy. This review focuses on the latest literature pertaining to the pathogenesis of IRIS.

RECENT FINDINGS

The clinical manifestations of IRIS are heterogeneous due to the variety of opportunistic infections that are associated with this inflammatory syndrome. However, the disproportionate inflammation is a defining hallmark for which common mechanisms are suspected. Lymphopenia-induced proliferation in the context of systemic immune activation, presence of high antigenic exposure and a wider availability of interleukin-7 contribute to the exacerbated immune response underlying IRIS. Defect in pathogen clearance by phagocytes might favor high pathogen burden, which in turn is thought to activate both innate immune cells and pathogen-specific T cells upon correction of the CD4 T-cell lymphopenia, predisposing to IRIS. This common scenario might be further invigorated by functional impairments among regulatory T cells.

SUMMARY

Further insight into the cellular mechanisms driving IRIS is urgently needed. Understanding the relative contribution of distinct effector and regulatory T-cell subsets, and innate immune components to IRIS is required to inspire future therapeutic approaches.

Impact of the immune reconstitution inflammatory syndrome (IRIS) on mortality and morbidity in HIV-infected patients in Mexico

OBJECTIVES

To estimate the impact of immune reconstitution inflammatory syndrome (IRIS) on morbidity and mortality in patients starting highly-active antiretroviral therapy (HAART).

METHODS

A retrospective cohort study of HIV-positive patients starting HAART was conducted at a tertiary care referral center in Mexico City. We estimated the incidence of IRIS, hospitalizations and death rates during the first 2 years of HAART. The relative risk of death (RR) and hospitalization for patients with IRIS were adjusted for relevant covariates using regression methods.

RESULTS

During the 2-year follow-up period, 27% of patients developed IRIS (14 IRIS cases per 100 person-years). The relative risk of death among patients who developed IRIS was 3 times higher (95% confidence interval (CI) 1.19-7.65, p = 0.03). After adjusting for previous opportunistic infections we still observed a higher death rate among patients with IRIS (RR 2.3, 95% CI 0.9-5.9, p=0.09). An effect modification of IRIS over mortality was observed by previous opportunistic infection.

CONCLUSIONS

IRIS-associated mortality is strongly confounded by previous opportunistic infection. Patients with AIDS who eventually developed IRIS had the highest risk of death at the 2-year follow-up.

Immune Reconstitution Inflammatory Syndrome

Immune reconstitution inflammatory syndrome (IRIS) is a phenomenon observed in patients recovering from immunodeficiency. The clinical presentation of IRIS involves the unmasking of covert infections or the worsening of overt conditions. Several causes and pathways have been suggested, most recognizing an inflammatory flare component occurring in the context of rapid immune reconstitution. In HIV-infected patients, IRIS inadvertently occurs as the consequence of successful antiretroviral therapy, and it is affiliated with improvement of the immune function, complicating the course of the disease and presenting treatment challenges to clinicians. The pathogenesis of IRIS is poorly understood, but in recovering HIV patients, its initiation and progression seem to be primarily linked to an increase in CD4+ T-helper and CD8+ T-suppressor cell count and a reduction in T-regulatory cells, all endorsed by exaggerated cytokine release and activity. The clinical presentation of IRIS is usually atypical. The manifestations depend on the trigger antigen, which can be an infective agent (viable or nonviable), a host antigen, or a tumor antigen. Most IRIS cases are self-limiting, but a few cases can be overwhelming and life-threatening; hence, early recognition is important. In most cases, there is no need to discontinue the antiretroviral therapy, although in the more severe cases, other clinical intervention may be necessary.

HIV-positive patient with herpes zoster: a manifestation of the immune reconstitution inflammatory syndrome

Herpes zoster is a common illness that can lead to serious morbidity. There is now evidence that HIV-infected patients who have been treated with antiretroviral therapy are at greater risk of developing herpes zoster not when they are severely immunocompromised but, paradoxically, when their immune system is recovering. This is a manifestation of the immune reconstitution inflammatory syndrome. The objectives of this report are to (1) inform health care providers that HIV-infected patients may develop multiple infectious, autoimmune, and oncological manifestations after treatment with antiretroviral medication, as they have immune system reconstitution, and (2) discuss herpes zoster, one of the possible manifestations. The patient is a 68-year-old HIV-positive man who presented with herpes zoster after being treated with highly active antiretroviral therapy (HAART) when his immune system was recovering, not when he was most immunosuppressed. Emergency department physicians should be aware that HIV-infected patients treated with HAART may have clinical deterioration despite immune system strengthening. This immune reconstitution inflammatory syndrome can present with infectious, autoimmune, or oncological manifestations. Our case patient, an HIV-positive man with immune system recovery after treatment with HAART, presented with an infectious manifestation, herpes zoster.

Recognition of immune reconstitution syndrome necessary for better management of patients with severe drug eruptions and those under immunosuppressive therapy

The immune reconstitution syndrome (IRS) is an increasingly recognized disease concept and is observed with a broad-spectrum of immunosuppressive therapy-related opportunistic infectious diseases and severe drug eruptions complicated by viral reactivations. Clinical illness consistent with IRS includes tuberculosis, herpes zoster, herpes simples, cytomegalovirus infections and sarcoidosis: thus, the manifestations of this syndrome and diverse and depend on the tissue burden of the preexisting infectious agents during the immunosuppressive state, the nature of the immune system being restored, and underlying diseases of the hosts. Although IRS has originally been reported to occur in the setting of HIV infection, it has become clear that the development of IRS can also be in HIV-negative hosts receiving immunosuppressive agents, such as prednisolone and tumor necrosis factor α inhibitors, upon their reduction and withdrawal. Drug-induced hypersensitivity syndrome, a life-threatening multiorgan system reaction, is another manifestation of the newly observed IRS. Clinical recognition of the IRS is especially important in improving the outcome for diseases with an otherwise life-threatening progenosis. Clinicians should be aware of the implications of IRS and recognize that relieving the symptoms and signs of immune recovery by anti-inflammatory therapies needs to be balanced with anti-microbial therapies aiming at reducing the amplitude and duration of tissue burden of preexisting microbes.

Superficial thrombophlebitis: A new clinical manifestation of the immune reconstitution inflammatory syndrome in a patient with HIV infection

Skin manifestations of immune reconstitution inflammatory syndrome in response to highly active antiretroviral therapy may account for up to 50% of the clinical presentations in this syndrome. Viable or dying infective antigens, host antigens, tumoral antigens, and others may target immune reconstitution inflammatory syndrome, resulting in a wide spectrum of clinical manifestations. We describe a 26-year-old HIV-infected man who had started highly active antiretroviral therapy a few months earlier. He developed multiple linear nodules following the superficial veins in both legs. Histopathologic examination demonstrated a mostly septal panniculitis with features of superficial thrombophlebitis. We propose that superficial thrombophlebitis should be added to the list of clinical manifestations of this newly observed immune restoration disease.

Update on immune reconstitution inflammatory syndrome: progress and unanswered questions

The immune reconstitution inflammatory syndrome (IRIS) is characterized by clinical deterioration occurring after the initiation of effective antiretroviral therapy (ART) and results from a disordered and exuberant immune response. The syndrome may present as paradoxical IRIS or unmasking IRIS, depending on whether an opportunistic infection was recognized and treated before ART initiation. Numerous descriptions of IRIS caused by many pathogens were published in the years after the introduction of effective ART. In recent years, with enhanced rollout of ART in resource-limited settings, attention has again focused on IRIS because of the enormous burden of opportunistic infections. This review highlights recent findings elucidating risk factors for and the pathogenesis and treatment of IRIS.

Immune reconstitution inflammatory syndrome

Immune reconstitution inflammatory syndrome (IRIS) must be considered in the differential diagnosis for any patient infected with HIV who has begun ART in the preceding months. Distinguishing between manifestations of IRIS and active infection is of paramount importance and poses a diagnostic challenge to the provider in the acute care setting. Presentations of IRIS are often atypical for the precipitating pathogen, and novel presentations are likely. Of the diseases associated with IRIS, mycobacteria and cryptococcal infections are commonly encountered, as are dermatologic symptoms in general. The most clinically significant complications of IRIS are those involving the central nervous system, lungs, and eye, and in many of these scenarios systemic steroids may be of benefit. Management should rarely include interruption of ART, except possibly in severe, life-threatening complications.

Immune restoration diseases reflect diverse immunopathological mechanisms

Up to one in four patients infected with human immunodeficiency virus type 1 and given antiretroviral therapy (ART) experiences inflammatory or cellular proliferative disease associated with a preexisting opportunistic infection, which may be subclinical. These immune restoration diseases (IRD) appear to result from the restoration of immunocompetence. IRD associated with intracellular pathogens are characterized by cellular immune responses and/or granulomatous inflammation. Mycobacterial and cryptococcal IRD are attributed to a pathological overproduction of Th1 cytokines. Clinicopathological characteristics of IRD associated with viral infections suggest different pathogenic mechanisms. For example, IRD associated with varicella-zoster virus or JC polyomavirus infection correlate with a CD8 T-cell response in the central nervous system. Exacerbations or de novo presentations of hepatitis associated with hepatitis C virus (HCV) infection following ART may also reflect restoration of pathogen-specific immune responses as titers of HCV-reactive antibodies rise in parallel with liver enzymes and plasma markers of T-cell activation. Correlations between immunological parameters assessed in longitudinal sample sets and clinical presentations are required to illuminate the diverse immunological scenarios described collectively as IRD. Here we present salient clinical features and review progress toward understanding their pathogeneses.

Immunopathogenesis of immune reconstitution disease in HIV patients responding to antiretroviral therapy

PURPOSE OF REVIEW

The aim of this article is to review the most recent literature regarding the immunopathogenesis of pathogen-associated immune reconstitution disease and to discuss the role of immune activation and various effector molecules and cells such as macrophages, effector and regulatory T cells, and natural killer cells in immune reconstitution disease.

RECENT FINDINGS

Many HIV patients receiving antiretroviral treatment develop immune reconstitution disease, which is characterized by exaggerated inflammatory immune responses to replicating or dead pathogens. In the majority of these cases, immune reconstitution disease is associated with restoration of pathogen-specific cellular immune responses involving CD4 or CD8 effector T cells. The precise conditions that trigger immune reconstitution disease have not yet been identified. Immune reconstitution disease patients have overt immune activation, which may be due to poor homeostatic control after the fast initial immune recovery in patients receiving antiretroviral therapy. Poor homeostatic control in immune reconstitution disease patients may be linked to unbalanced restoration of effector and regulatory T cells.

SUMMARY

Although the precise mechanism of immune reconstitution disease is not well understood, it is probably related to rapid restoration of pathogen-specific immune responses and poor homeostatic control that promote exaggerated immunopathological responses, especially if viable pathogens or pathogen debris are present at high concentrations.

Influence of systemic immune and cytokine responses during the acute phase of zoster on the development of postherpetic neuralgia

Postherpetic neuralgia (PHN) is a severe sequela of herpes zoster (HZ). Until now, only age and pain severity were considered predisposing factors for the development of PHN. We evaluated 49 patients with acute phase HZ, 10 of whom developed PHN (Group A) and 39 of whom did not develop PHN (Group B). Twenty-five healthy volunteers similar in age and gender distribution to the study group were recruited as controls (Group C). Numbers of serum CD3(+) (pan-T lymphocytes), CD4(+) (helper/inducer), and CD8(+) (suppressor/cytotoxic) lymphocytes were decreased significantly in Groups A and B relative to the control group, but there were no statistical differences between Groups A and B. Interleukin (IL)-1beta, IL-6, tumor necrosis factor (TNF)-alpha, IL-8, and IL-10 were significantly elevated in Groups A and B relative to Group C. IL-6 was significantly higher in Group A than in Group B, and was significantly positively correlated with pain severity scored on a visual analog scale. Therefore, we suggest that the inflammatory response, especially that of IL-6, in the acute phase of HZ may be associated with hyperalgesia and the development of PHN.

Disseminated herpes zoster with increased CD4 counts in 3 HIV-infected patients

It has been reported that the diagnosis of multidermatomal herpes zoster in HIV-infected patients occurs at a lower CD4 level than zoster involving a single dermatome. Herein, we describe 3 cases of HIV-infected patients presenting with disseminated zoster at high CD4 counts and low HIV viral loads.

[Human immunodeficiency virus and AIDS-associated immune reconstitution syndrome. State of the art]

Since the arrival of highly active antiretroviral therapy (HAART), immune reconstitution syndrome (IRS) has become an increasingly more frequent complication in patients with human immunodeficiency virus (HIV) infection. This article presents a review of the available evidence on this subject, indexed in MEDLINE-PUBMED, BVS-BIREME, and BioMed Central. The review covers the definition, epidemiology, classification, and diagnostic criteria related to IRS. In addition, the clinical particularities of the most frequent etiologies are described, and a proposal for a therapeutic approach is formulated. The prognosis and future implications of this syndrome in the epidemiology of some infectious illnesses in the HIV-positive population are included. Several unresolved aspects are mentioned, such as those related to the pathophysiology of the condition, use of biomarkers for the diagnosis, and the need for evidence-based therapeutic algorithms to enable standardization of treatment for these patients.

Polychromatic immunophenotypic characterization of T cell profiles among HIV-infected patients experiencing immune reconstitution inflammatory syndrome (IRIS)

Objective

To immunophenotype CD4⁺ and CD8⁺ T cell sub-populations in HIV-associated immune reconstitution inflammatory syndrome (IRIS).

Design

Nested case-control immunological study.

Methods

ART-naïve HIV-infected patients were prospectively observed for IRIS during the first 6 months of ART. Twenty-two IRIS cases and 22 ART-duration matched controls were sampled for T cell immunophenotyping.

Results

IRIS cases demonstrated significantly lower CD4 cell counts compared to controls (baseline: 79 versus 142, p = 0.02; enrollment: 183 versus 263, p = 0.05, respectively) with no differences in HIV RNA levels. Within CD4⁺T cells, cases exhibited more of an effector memory phenotype compared to controls (40.8 versus 27.0%, p = 0.20), while controls trended towards a central memory phenotype (43.8 versus 30.8%, p = 0.07). Within CD8⁺ T cells, controls exhibited more central memory (13.9 versus 7.81%, p = 0.01, respectively) and effector (13.2 versus 8.8%, p = 0.04, respectively) phenotypes compared to cases, whereas cases demonstrated more terminal effectors than controls (28.8 versus 15.1%, p = 0.05). Cases demonstrated increased activation of CD8⁺ T cell effector memory, terminal effector, and effector subsets than controls (p = 0.04, 0.02, and 0.02, respectively).

Conclusion

CD4⁺ and CD8⁺ T cell subset maturational phenotypes were heterogeneous among IRIS cases and controls. However, IRIS cases demonstrated significant increases in activation of CD8⁺ T cell effector subpopulations.

Fulminant varicella hepatitis in a human immunodeficiency virus infected patient: Case report and review of the literature

We report the case of a 35-y-old HIV-infected female, who presented fulminant varicella hepatitis and recovered under medical treatment. Varicella zoster virus is an uncommon cause of acute liver disease which occurs mainly in immunocompromised patients. Acyclovir is the cornerstone of the treatment.

Identification of oral candidosis, hairy leukoplakia and recurrent oral ulcers as distinct cases of immune reconstitution inflammatory syndrome

Oral lesions such as candidosis, hairy leukoplakia (HL) and oral ulcers are strikingly absent in the numerous reports of immune reconstitution inflammatory syndrome (IRIS). To document oral manifestations attributable to immune reconstitution, we conducted a longitudinal follow-up of a cohort of HIV+ individuals starting highly active antiretroviral therapy (HAART) and completing oral pathology follow-up up to 12 weeks after treatment initiation. HIV-infected patients had oral examinations, CD4+ T-cell count and viral load determinations performed at baseline, and at weeks 4, 8 and 12 after HAART initiation. Among individuals with satisfactory viral response and recovery of ≥50 CD4+ T-cell/µL, eight patients complied with strict IRIS criteria: two developed clinical signs of oral candidosis (OC), two oral ulcers, three HL and one Kaposi's sarcoma. CD4+ T-cell counts at symptom onset suggested no remaining immune suppression. Our findings show that cases of OC, HL and recurrent ulcers can be instances of IRIS.

Short-term and long-term effects of highly active antiretroviral therapy on the incidence of herpes zoster in HIV-infected children

BACKGROUND

Highly active antiretroviral therapy (HAART) has reduced herpes zoster (HZ) incidence in HIV-infected children, yet it remains common.

METHODS

We evaluated perinatally HIV-infected youth with varicella infection enrolled between 1993 and 2006 in a prospective cohort study. Incidence rates (IRs) and 95% confidence intervals of HZ were estimated by calendar year, age group, and HAART use. The effect of initiating HAART was also evaluated by fitting Cox survival models adjusted for potential confounders.

RESULTS

Among 536 perinatally infected children with documented prior varicella (median follow-up = 6.8 years), 116 (22%) developed HZ (IR = 3.2 events/100 person-years, confidence interval: 2.6 to 3.8). IRs increased from 1993 to 1996 and then declined significantly through 2006 (P < 0.001). However, an IR of 1.4-3.1 HZ episodes per 100 person-years persisted from 2001 to 2006. The risk of HZ was higher for those with lower CD4% or in Centers for Disease Control and Prevention clinical class C. The IR of HZ was similar in the 90 days before or after initiation of HAART but declined significantly after more than 90 days of HAART.

CONCLUSIONS

Although HAART has markedly reduced the IR of HZ, it remains a frequent complication in HIV-infected children. The risk of HZ is similar in the 90 days before and after initiating HAART.