The immune reconstitution inflammatory syndrome with tuberculosis: a common problem in Ethiopian HIV-infected patients beginning antiretroviral therapy

Immune reconstitution inflammatory syndrome, a controversial burden in the East African context: a systematic review and meta-analysis

Introduction

It is well established that starting antiretroviral therapy (ART) increases a patient's life expectancy among HIV-positive individuals. Considering the HIV pandemic, the major concern is initiation of ARTs to the large segment of HIV infected population, not adverse events from immune restoration. The prevalence of HIV-associated immune reconstitution inflammatory syndrome (IRIS) is poorly estimated due to Africa's underdeveloped infrastructure, particularly in Eastern Africa. Therefore, this study compiled data regarding the magnitude and associated factors of IRIS in the context of Eastern Africa.

Methods

The electronic databases such as Google Scholar, PubMed, Web of Science, and free Google access were searched till 5 June 2021, and the search was lastly updated on 30 June 2022 for studies of interest. The pooled prevalence, and associated factors with a 95% confidence interval were estimated using the random effects model. The I2 and Egger's tests were used for heterogeneity and publication bias assessment, respectively.

Results

The development of HIV-associated IRIS in Eastern Africa was estimated to be 18.18% (95% CI 13.30-23.06) in the current review. The two most common predictors of IRIS associated with Eastern Africa were the lower pre-ART CD4 T-cell count of 50 cells/μl and the low baseline body mass index level. Therefore, attention should be focused on the early detection and care of HIV-associated IRIS to reduce the morbidity and death caused by IRIS.

Tuberculosis-Associated Immune Reconstitution Inflammatory Syndrome-An Extempore Game of Misfiring with Defense Arsenals

The lethal combination involving TB and HIV, known as "syndemic" diseases, synergistically act upon one another to magnify the disease burden. Individuals on anti-retroviral therapy (ART) are at risk of developing TB-associated immune reconstitution inflammatory syndrome (TB-IRIS). The underlying inflammatory complication includes the rapid restoration of immune responses following ART, eventually leading to exaggerated inflammatory responses to MTB antigens. TB-IRIS continues to be a cause of morbidity and mortality among HIV/TB coinfected patients initiating ART, and although a significant quantum of knowledge has been acquired on the pathogenesis of IRIS, the underlying pathomechanisms and identification of a sensitive and specific diagnostic marker still remain a grey area of investigation. Here, we reviewed the latest research developments into IRIS immunopathogenesis, and outlined the modalities to prevent and manage strategies for better clinical and diagnostic outcomes for IRIS.

The Effect of Long-Term HAART on the Incidence of Tuberculosis Among People Living with HIV in Addis Ababa, Ethiopia: A Matched Nested Case-Control Study

Background

The introduction of antiretroviral therapy (ART) significantly decreases the incidence of tuberculosis (TB) in people living with human immunodeficiency virus (PLWHIV). However, a considerable proportion is still co-infected with TB after ART initiation. Thus, this study aimed to assess the effect of long-term HAART on the incidence of TB among PLWHIV in Addis Ababa, Ethiopia.

Methods

A matched nested case–control study was conducted among PLWHIV who were enrolled in ART clinics in Addis Ababa, Ethiopia from 2013 up to 2018. Cases were HIV-TB co-infected individuals who were taking antiretroviral treatment, while controls were PLWHIV without TB who were taking antiretroviral treatment. The cases and controls are matched exactly in age and sex. Data were entered in Epi Info version 7.1 and analyzed using SPSS version 20. Bi-variable and multivariable conditional logistic regression were employed along with 95% CI. A P-value <0.05 in the multivariable analysis was considered statistically significant.

Results

Fifty-seven cases were compared with 114 controls. Accordingly, previous TB history (X²; 13.790, P < 0.001), baseline functional status (X²; 9.120, P = 0.010), baseline WHO clinical stage (X²; 10.083, P = 0.001), baseline hemoglobin value (X²; 6.985, P = 0.008), baseline body mass index (X²; 3.873, P = 0.049), isoniazid preventive treatment (X²; 8.047, P = 0.005), baseline CD4 value (X²; 12.741, P < 0.001) and length of stay on ART (X²; 53.359, P < 0.001) were associated with developing TB. Length of stay on ART was found to be the statistically significant determinant of TB infection after ART initiation (aOR = 5.925, 95% CI = 2.649–13.250).

Conclusion

Advanced clinical stages at the baseline, previous TB history, and not taking IPT were associated with TB infection. The long-term ART exposure significantly decreases tuberculosis incidence in PLWHIV. Thus, retaining PLWHIV on ART would be important to decrease the incidence of TB in this group of individuals.

Prevalence and risk factors of paradoxical tuberculosis associated immune reconstitution inflammatory syndrome among HIV-infected patients in Beijing, China

Background

In this study, we aimed to describe the prevalence, clinical presentation and risk factors of paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) cases in China.

Methods

We performed a descriptive analysis of demographic and clinical data of HIV/TB coinfected patients receiving ART at Beijing Ditan Hospital between January 2014 and October 2018.

Results

Of 199 patients included, 45 (22.6%) developed paradoxical TB-IRIS, and 19 (9.5%) TB-IRIS cases presented miliary TB. The pre-ART CD4 count lower than 50 cells/mm³ was found to be significantly associated with development of TB-IRIS. Similarly, patients with higher than 4-fold increase in CD4 cell count after antiretroviral therapy (ART) had significantly higher odds of having TB-IRIS. When patients aged 25–44 years were utilized as the control group, youths (< 25 years old) were more likely to have miliary TB. No significant difference was observed in the intervals from initiation of ART to IRIS presentation between miliary and non-miliary group.

Conclusions

In conclusion, our data demonstrate that approximate one quarter of patients coinfected with TB and HIV develop paradoxical TB-IRIS after initial of ART therapy in China. Lower baseline CD4 count and rapid increase in CD4 count are the major risk factors associated with the occurrence of paradoxical TB-IRIS.

Paradoxical TB-IRIS in HIV-infected adults: a systematic review and meta-analysis

Paradoxical tuberculosis immune reconstitution inflammatory syndrome (TB-IRIS) was first described almost two decades ago. We undertook this systematic review and meta-analysis to collate findings across studies that have reported the incidence, clinical features, management and outcomes of paradoxical TB-IRIS. Forty studies that cumulatively reported 1048 paradoxical TB-IRIS cases were included. The pooled estimated incidence among patients with HIV-associated TB initiating antiretroviral therapy was 18% (95% CI: 16-21%). Frequent features were pulmonary and lymph node involvement. Hospitalization occurred in 25% (95% CI: 19-30%). In studies that reported treatment, corticosteroids were prescribed more frequently (38%; 95% CI: 27-48%) than nonsteroidal anti-inflammatory drugs (28%; 95% CI: 2-53%). Case fatality was 7% (95% CI: 4-11%), but death attributed to TB-IRIS occurred in 2% of cases (95% CI: 1-3%).