Hypercalcemia Related to Immune Reconstitution in Organ Transplant Recipients with Granulomatous Opportunistic Infections

Tuberculosis‐immune reconstitution inflammatory syndrome in HIV ‐negative children

Even though tuberculosis‐immune reconstitution inflammatory syndrome (TB‐IRIS) is usually found in HIV‐positive patients receiving antiviral treatment, it can also occur in HIV‐negative patients especially if they have risk factors. We report a unique case of TB‐IRIS in an immunocompetent child presenting with new onset of pleuritic chest pain after receiving anti‐TB drugs. TB‐IRIS should be considered as a differential diagnosis in case of clinical deterioration or appearance of new typical lesions despite appropriate anti‐TB treatment for more than 2 weeks in the absence of persistently active TB or any other alternative causes. This will prevent physicians from misdiagnosis as superimposed infections, treatment failure or TB relapse.

Treatment with Tumor Necrosis Factor-α Inhibitors, History of Allergy, and Hypercalcemia Are Risk Factors of Immune Reconstitution Inflammatory Syndrome in HIV-Negative Pulmonary Tuberculosis Patients

Immune reconstitution inflammatory syndrome (IRIS) is an immune reaction that occurs along with the recovery of the patient’s immunity. Tuberculosis-related IRIS (TB-IRIS) upon tumor necrosis factor (TNF)-α inhibitor treatment has been reported in non-human immunodeficiency virus (HIV) patients. However, the importance of biological treatment, as a risk factor of IRIS, has not yet been established. In this study, we examined TB-IRIS in non-HIV patients to explore the role of TNF-α inhibitor treatment. Out of 188 patients with pulmonary TB, seven patients had IRIS. We examined univariate logistic and multivariate analysis to elucidate risk factors of TB-IRIS. Univariate analysis indicated that usage of immunosuppressive drugs, TNF-α inhibitors, and history of food or drug allergy were significantly related with TB-IRIS. On initial treatment, the values of serological markers such as serum albumin and serum calcium were significantly related with TB-IRIS. There was a higher mortality rate in patients with TB-IRIS. Furthermore, multivariate analysis revealed that usage of TNF-α inhibitors, history of allergy, and serum hypercalcemia were related to TB-IRIS. Usage of TNF-α inhibitors, history of allergy, and serum hypercalcemia may be independent predictors of TB-IRIS in non-HIV patients. Since higher mortality has been reported for TB-IRIS, we should pay attention to TB patients with these risk factors.

Understanding Pathogenesis and Care Challenges of Immune Reconstitution Inflammatory Syndrome in Fungal Infections

Immune deficiency of diverse etiology, including human immunodeficiency virus (HIV), antineoplastic agents, immunosuppressive agents used in solid organ recipients, immunomodulatory therapy, and other biologics, all promote invasive fungal infections. Subsequent voluntary or unintended immune recovery may induce an exaggerated inflammatory response defining immune reconstitution inflammatory syndrome (IRIS), which causes significant mortality and morbidity. Fungal-associated IRIS raises several diagnostic and management issues. Mostly studied with Cryptococcus, it has also been described with other major fungi implicated in human invasive fungal infections, such as Pneumocystis, Aspergillus, Candida, and Histoplasma. Furthermore, the understanding of IRIS pathogenesis remains in its infancy. This review summarizes current knowledge regarding the clinical characteristics of IRIS depending on fungal species and existing strategies to predict, prevent, and treat IRIS in this patient population, and tries to propose a common immunological background to fungal IRIS.

Immune reconstitution inflammatory syndrome in non-HIV immunocompromised patients

PURPOSE OF REVIEW

In the era of highly active antiretroviral therapy, immune reconstitution inflammatory syndrome has become well recognized in the HIV-infected population. However, little is known about its occurrence in non-HIV immunocompromised hosts. The present review aims to propose the pathogenesis of immune reconstitution inflammatory syndrome, summarize its occurrence in immunocompromised patients without HIV infection, and suggest potential treatment options.

RECENT FINDINGS

Immune reconstitution inflammatory syndrome is exuberant and dysregulated inflammatory responses to invading microorganisms. It manifests when an abrupt shift of host immunity from an anti-inflammatory and immunosuppressive status towards a pathogenic proinflammatory state occurs as a result of rapid decreases or removal of factors promoting immunosuppression or inhibiting inflammation. In addition to HIV-infected patients, immune reconstitution inflammatory syndrome has also been observed in solid organ transplant recipients, women during the postpartum period, neutropenic patients, and tumor necrosis factor antagonist recipients. Corticosteroids are the most commonly employed treatment, whereas other potential agents based on its pathogenesis deserve further investigation.

SUMMARY

Non-HIV immunocompromised hosts develop immune reconstitution inflammatory syndrome when the sudden change in the dominant T helper responses to inflammation is not well balanced by anti-inflammatory responses. Judicious manipulation of host immunity and timely recognition of immune reconstitution inflammatory syndrome as we deal with the infections in these populations is critical to limit or avoid the harm by immune reconstitution inflammatory syndrome.