Immune reconstitution inflammatory syndrome associated with PML in AIDS: A treatable disorder

Neurologic Infections in Patients on Immunomodulatory and Immunosuppressive Therapies

PURPOSE OF REVIEW

Both broadly immunosuppressive medications and selective immunomodulatory agents that act on particular components of the immune system are increasingly used in the treatment of neurologic and non-neurologic diseases. These therapies predispose patients to particular infections, some of which may affect the nervous system. Therefore, familiarity with the clinical and radiologic features of neurologic infections associated with specific immunomodulatory therapies is of importance for the practicing neurologist. This article reviews these neuroinfectious conditions, as well as other neurologic complications unique to transplant recipients and other patients who are immunocompromised.

RECENT FINDINGS

Diagnosis of infectious pathogens in patients who are immunocompromised may be particularly challenging because a decreased immune response can lead to atypical imaging or laboratory findings. Next-generation sequencing and other novel diagnostic modalities may improve the rate of early identification of neurologic infections in patients who are immunocompromised and ultimately ameliorate outcomes in this vulnerable population.

SUMMARY

A broad range of bacterial, viral, fungal, and parasitic infections of the nervous system can complicate solid organ and hematopoietic cell transplantation as well as other forms of immunocompromise. In addition to neurologic infections, such patients are at risk of neurotoxic and neuroinflammatory complications related to immunomodulatory and immunosuppressive therapies. Early recognition of infectious and noninfectious complications of immunocompromise is essential to guide appropriate treatment, which can include antimicrobial therapy and, in some cases, withdrawal of the predisposing medication with a transition to an alternative regimen.

[Progressive multifocal encephalopathy in neurological practice]

Progressive multifocal leukoencephalopathy (PML) is considered so far as a rare rapidly progressive demyelinating CNS disease caused by the JC virus activation. Current data suggest that PML developed in people with impaired immunity. However, in some cases PML developed in the absence of severe immunological deficit. In clinical practice, the early diagnosis of PML is difficult because symptoms are mild and, therefore, the physician should be familiar with diagnostic criteria of this disease to make the correct diagnosis and start the symptomatic therapy as soon as possible. This will help to improve patient's state though there is no effective treatment of PML so far. Up to the present moment, antiviral medications, cytostatic drugs, serotonin receptor antagonists, plasmapheresis are widely used. These methods can be used only if the causes of PML have been identified while the patient needs urgent help. Thus, the schemes of pathogenetic treatment with the drugs with pleiotropic effects should be used.

The Risk of Progressive Multifocal Leukoencephalopathy in the Biologic Era: Prevention and Management

Progressive multifocal leukoencephalopathy (PML) is a rare, typically fatal, demyelinating central nervous system infection caused by reactivation of the John Cunningham virus that generally occurs in immunosuppressed patients. With an evolving understanding of a greater clinical heterogeneity of PML and significant implications for therapy, PML should be considered in the differential diagnosis of neurologic presentations of rheumatic diseases. Increased awareness of PML among rheumatologists is required, as earlier diagnosis and restoration of immune function may improve the otherwise grim prognosis associated with PML.

Immune Reconstitution Inflammatory Syndrome Unmasking or Worsening AIDS-Related Progressive Multifocal Leukoencephalopathy: A Literature Review

Incidence of progressive multifocal leukoencephalopathy (PML) in HIV-infected patients has declined in the combined antiretroviral therapy (cART) era although a growing number of acquired immunodeficiency syndrome (AIDS)-related PML-immune reconstitution inflammatory syndromes (PML-IRIS) have been published during the same period. Therapeutic management of PML-IRIS is not consensual and mainly relies on corticosteroids. Our main aim was, in addition to provide a thoughtful analysis of published PML-IRIS cases, to assess the benefit of corticosteroids in the management of PML-IRIS, focusing on confirmed cases. We performed a literature review of the 46 confirmed cases of PML-IRIS cases occurring in HIV-infected patients from 1998 to September 2016 (21 unmasking and 25 paradoxical PML-IRIS). AIDS-related PML-IRIS patients were mostly men (sex ratio 4/1) with a median age of 40.5 years (range 12-66). Median CD4 T cell count before cART and at PML-IRIS onset was 45/μl (0-301) and 101/μl (20-610), respectively. After cART initiation, PML-IRIS occurred within a median timescale of 38 days (18-120). Clinical signs were motor deficits (69%), speech disorders (36%), cognitive disorders (33%), cerebellar ataxia (28%), and visual disturbances (23%). Brain MRI revealed hyperintense areas on T2-weighted sequences and FLAIR images (76%) and suggestive contrast enhancement (87%). PCR for John Cunningham virus (JCV) in cerebrospinal fluid (CSF) was positive in only 84% of cases; however, when performed, brain biopsy confirmed diagnosis of PML in 90% of cases and demonstrated histological signs of IRIS in 95% of cases. Clinical worsening related to PML-IRIS and leading to death was observed in 28% of cases. Corticosteroids were prescribed in 63% of cases and maraviroc in one case. Statistical analysis failed to demonstrate significant benefit from steroid treatment, despite spectacular improvement in certain cases. Diagnosis of PML-IRIS should be considered in HIV-infected patients with worsening neurological symptoms after initiation or resumption of effective cART, independently of CD4 cell count prior to cART. If PCR for JCV is negative in CSF, brain biopsy should be discussed. Only large multicentric randomized trials could potentially demonstrate the possible efficacy of corticosteroids and/or CCR5 antagonists in the management of PML-IRIS.

Predictors and characteristics of seizures in survivors of progressive multifocal leukoencephalopathy

This study aims to determine the risk factors for epileptogenesis and characteristics of seizures in patients with progressive multifocal leukoencephalopathy (PML) who survive more than 1 year from onset of neurological symptoms (PML survivors). We reviewed clinical data including seizure history and MR imaging studies from PML survivors evaluated at our institution between 1997 and 2014. PML progressors who passed away within 1 year and patients with a history of seizures prior to PML diagnosis were excluded from the analysis. Of 64 PML survivors, 28 (44 %) developed seizures. The median time from the onset of PML symptoms to the first seizure was 5.4 months (range 0-159) and 64 % of patients with seizures had them within the first year. The presence of juxtacortical PML lesions was associated with a relative risk of seizures of 3.5 (p < 0.02; 95 % confidence interval (CI) 1.3-9.4) in multivariate analyses. Of all seizure types, 86 % were focal and 60 % most likely originated from the frontal lobes. Among seizure patients, 89 % required treatment, including one (54 %), two (25 %), or three (10.5 %) antiepileptic drugs. Seizures are a frequent complication in PML and can develop throughout the entire course of the disease. However, late onset seizures did not signify PML relapse. Seizures may require treatment with multiple antiepileptic medications and are a significant co-morbidity in PML.

Incidence and prognosis of immune reconstitution inflammatory syndrome in HIV-associated progressive multifocal leucoencephalopathy

BACKGROUND AND PURPOSE

Progressive multifocal leucoencephalopathy-associated immune reconstitution inflammatory syndrome (PML-IRIS) is the paradoxical worsening or unmasking of preexisting infection with JC virus attributable to a rapid recovery of the immune system after highly active antiretroviral therapy (HAART) initiation. We investigated the incidence and factors associated with PML-IRIS in HIV-infected patients. We also studied its influence on mortality of PML and the effect of corticosteroid therapy.

METHODS

Single-center retrospective analysis of HIV-infected patients diagnosed with PML from 1996 to 2012 who received HAART.

RESULTS

Among 59 PML patients treated with HAART, 18 (30.51%) developed PML-IRIS (five delayed PML-IRIS, 13 simultaneous PML-IRIS). Patients who developed IRIS had lower CD4 counts prior to treatment (102 vs. 68.5, P < 0.05) and experienced a greater decline in HIV-RNA levels in response to HAART (2.5log vs. 2.95log, P < 0.05). Gadolinium enhancement on MRI was observed in 31.25% of PML-IRIS cases versus 2.56% of PML non-IRIS (P < 0.01). Survival rates were higher in patients with PML-IRIS compared to those with PML non-IRIS. Eight patients received corticosteroids, five of which had a good outcome. Patients who died were severely ill when treatment was initiated whereas patients who survived were treated before major neurological deterioration occurred.

CONCLUSIONS

Nearly one-third of HIV-infected patients with PML develop IRIS after initiating HAART. Patients severely immunocompromised who experience a rapid virological response to HAART have a higher risk for PML-IRIS. There was a trend for lower mortality in patients with IRIS. Early treatment with corticosteroids might be useful.

Immune Reconstitution Inflammatory Syndrome in Acquired Immune Deficiency Syndrome related to Cryptococcal Meningoencephalitis

Background. Highly active antiretroviral therapy (HAART) has contributed to reducing the occurrence of opportunistic infections and mortality in human immunodeficiency virus (HIV) infected patients. However, a paradoxical worsening of clinical signs and symptoms among patients during HAART may occur. Immune reconstitution inflammatory syndrome (IRIS) is described as a paradoxical deterioration of clinical status on initiation of HAART in patients with HIV infection. Case Report. We describe the case of a 41-year-old man with opportunistic cryptococcal encephalitis who exhibited neurological and radiological deterioration during the course of HAART. A diagnosis of central nervous system (CNS)-IRIS was based on a decrease of HIV-RNA viral load greater than 1 log, with an increase in CD4⁺ T-cell count from baseline. Conclusions. Differential diagnosis of this paradoxical deterioration in clinical and neurological status from overwhelming opportunistic infection is important; it enables an avoidance of unnecessary diagnostic procedures and proper management of this HIV-associated CNS disorder.

A Rare Case of Immune Reconstitution Inflammatory Syndrome Development in an Immunocompromised Patient with Progressive Multifocal Leukoencephalopathy and Multicentric Castleman's Disease

Immune reconstitution inflammatory syndrome (IRIS) development in HIV with preexistent progressive multifocal leukoencephalopathy (PML) has been extensively studied. PML-IRIS typically manifests clinically as new or worsening neurologic symptoms in conjunction with enlarging CNS lesions and occurs in approximately 10–20 percent of HIV-infected patients with PML who begin HAART. Likewise, Multicentric Castleman's Disease (MCD), a rare malignant lymphoproliferative disorder, has a strong and well-known association with HIV. Our case provides a rare instance of PML-IRIS in combination with MCD in an HIV-positive individual. The combination of all three diseases has never been reported in the literature. Both MCD and PML were present during initial determination of HIV infection in our patient and their disease courses were altered during the subsequent development of IRIS.

Management of the immune reconstitution inflammatory syndrome

The immune reconstitution inflammatory syndrome (IRIS) is a frequent early complication of antiretroviral therapy (ART) in patients with advanced HIV. Because there is no confirmatory diagnostic test, the diagnosis is based on clinical presentation and exclusion of alternative causes for deterioration, such as antimicrobial drug resistance. Opportunistic infection treatment should be optimized. Mild cases may require symptomatic therapy alone or nonsteroidal anti-inflammatory drugs. Corticosteroids have been used to treat more severe cases of IRIS associated with mycobacterial and fungal infections. There is evidence from a randomized controlled trial that prednisone reduces morbidity and improves symptoms in paradoxical tuberculosis (TB)-IRIS. Neurological TB-IRIS is potentially life-threatening; high-dose corticosteroids are indicated and ART interruption should be considered if level of consciousness is depressed. When considering corticosteroid treatment clinicians should be aware of their side effects and only use them when the diagnosis of IRIS is certain. In viral forms of IRIS corticosteroids are generally avoided.

Progressive multifocal leukoencephalopathy

Treatment of progressive multifocal leukoencephalopathy (PML) in a patient with exogenous immunosuppression starts with discontinuation of immunosuppressive medication. The restored host immunity will clear JC virus, the cause of PML, from the brain via cell-mediated immune mechanisms. Patients with solid-organ transplants will lose the transplanted organ, however, and patients who have autoimmune disorders may experience exacerbation of their underlying disease. These factors need to be weighed against the potentially fatal nature of PML. If the patient's immunosuppression is AIDS-related, highly active antiretroviral therapy (HAART) should be initiated if it has not previously been used. If the patient is already receiving HAART, the therapy should be changed to optimize treatment, with the goals of a nondetectable HIV viral load and normalization or near normalization of the CD4 count. For non-AIDS PML patients, daily intravenous cytosine arabinoside for 5 days can be offered if the patient is not pancytopenic and can tolerate a chemotherapeutic agent. For AIDS patients with PML or failing non-AIDS patients with neurologic deterioration, cidofovir can be considered. These therapies can be offered if neurologic stabilization satisfies the quality-of-life goals for the patient. For patients intolerant of other therapies or unsuited to them, oral mirtazapine or risperidone can be considered. The safety of these agents has been established in the treatment of psychiatric disease, but their efficacy has not yet been proven. Small interfering RNA (siRNA) therapy holds the promise of specific antiviral therapy, but delivery methods, safety, and efficacy are yet to be established.

Immune reconstitution inflammatory syndrome: incidence and implications for mortality

OBJECTIVE

To describe incidence of immune reconstitution inflammatory syndrome (IRIS) and its association with mortality in a large multisite US HIV-infected cohort applying an objective, comprehensive definition.

DESIGN

We studied 2,610 patients seen during 1996-2007 who initiated or resumed highly active combination antiretroviral therapy (cART) and, during the next 6 months, demonstrated a decline in plasma HIV-RNA viral load of at least 0.5 log(10) copies/ml or an increase of at least 50% in CD4 cell count per microliter. We defined IRIS as the diagnosis of a type B or C condition [as per the Centers for Disease Control and Prevention (CDC) 1993 AIDS case definition] or any new mucocutaneous disorder during this same 6-month period.

METHODS

We assessed the incidence of IRIS and evaluated risk factors for IRIS using conditional logistic regression and for all-cause mortality using proportional hazards models.

RESULTS

We identified 370 cases of IRIS (in 276 patients). Median and nadir CD4 cell counts at cART initiation were 90 and 43 cells/μl, respectively; median viral load was 2.7 log(10) copies/ml. The most common IRIS-defining diagnoses were candidiasis (all forms), cytomegalovirus infection, disseminated Mycobacterium avium intracellulare, Pneumocystis pneumonia, varicella zoster, Kaposi's sarcoma and non-Hodgkin lymphoma. Only one case of Mycobacterium tuberculosis was observed. IRIS was independently associated with CD4 cell count less than 50 cells/μl vs. at least 200 cells/μl [odds ratio (OR) 5.0] and a viral load of at least 5.0 log(10) copies vs. less than 4.0 log(10) copies (OR 2.3). IRIS with a type B-defining or type C-defining diagnosis approximately doubled the risk for all-cause mortality.

CONCLUSION

In this large US-based HIV-infected cohort, IRIS occurred in 10.6% of patients who responded to effective ART and contributed to increased mortality.

Central nervous system immune reconstitution inflammatory syndrome in AIDS: experience of a Mexican neurological centre

BACKGROUND

Highly active antiretroviral therapy (HAART) restores the inflammatory immune response in AIDS patients and it may unmask previous subclinical infections or paradoxically exacerbate symptoms of opportunistic infections. Up to 25% of patients receiving HAART develop immune reconstitution inflammatory syndrome (IRIS). We describe six patients with IRIS central nervous system (CNSIRIS) manifestations emphasizing the relevance of CSF cultures and neuroimaging in early diagnosis and management.

METHODS

Patients with CNSIRIS were identified among hospitalized HIV-infected patients that started HAART from January 2002 through December 2007 at a referral neurological center in Mexico.

RESULTS

One-hundred and forty-two HIV-infected patients with neurological signs were hospitalized, 64 of which had received HAART, and six (9.3%) developed CNSIRIS. Five patients were male. Two cases of tuberculosis, two of cryptococcosis, one of brain toxoplasmosis, and one possible PML case were found. IRIS onset occurred within 12 weeks of HAART in five patients. Anti-infective therapy was continued. In one case, HAART was temporarily suspended. In long-term follow-up the clinical condition improved in all patients.

CONCLUSIONS

CNSIRIS associated to opportunistic infections appeared in 9% of patients receiving HAART. Interestingly, no cases of malignancy or neoplasm IRIS-related were found. Frequent clinical assessment and neuroimaging studies supported diagnosis and treatment. Risk factors were similar to those found in other series.

Immune reconstitution is not a prognostic factor in progressive multifocal leukoencephalopathy

Progressive multifocal leukoencephalopathy (PML) is typically associated with minimal inflammation; however, patients may develop an inflammatory response due to immune reconstitution (IRIS). The authors aimed to determine if characteristics and outcomes of PML are altered in those with IRIS. A retrospective records review was performed on 87 patients diagnosed with PML at Johns Hopkins, 27 of which had a syndrome consistent with IRIS. Gadolinium enhancement on MRI occurred in 44.4% of cases of PML-IRIS versus 5.1% in PML (p<0.05), and thus had low diagnostic sensitivity and specificity. In HIV+ cases, CD4 counts were lower in those who later developed IRIS (mean 34.8 vs. 71.7, p<0.05) and was predictive of the development of IRIS (p<0.05). Improved prognosis was seen with higher cerebrospinal fluid (CSF) white blood cell counts and protein levels, but not for gadolinium enhancement and there were no differences in survival for PML versus PML-IRIS.

The immune reconstitution inflammatory syndrome and antiretroviral therapy

Although generally mild, severe immune reconstitution inflammatory syndrome may complicate antiretroviral therapy, and it may be difficult to differentiate from treatment failure or toxicity. This article looks at diagnostic and therapeutic challenges of severe infectious manifestations of immune reconstitution inflammatory syndrome.

Progressive multifocal leukoencephalopathy and other disorders caused by JC virus: clinical features and pathogenesis

Progressive multifocal leukoencephalopathy (PML) is a rare but often fatal brain disease caused by reactivation of the polyomavirus JC. Knowledge of the characteristics of PML has substantially expanded since the introduction of combination antiretroviral therapy during the HIV epidemic and the development of immune reconstitution inflammatory syndrome (IRIS) in patients with PML. Recently, the monoclonal antibodies natalizumab, efalizumab, and rituximab--used for the treatment of multiple sclerosis, psoriasis, haematological malignancies, Crohn's disease, and rheumatic diseases--have been associated with PML. Additionally, the JC virus can also lead to novel neurological disorders such as JC virus granule cell neuronopathy and JC virus encephalopathy, and might also cause meningitis. The increasingly diverse populations at risk and the recent discovery of the presence of the JC virus in the grey matter invite us to reappraise the pathogenesis of this virus in the CNS.

Viral meningoencephalitis: a review of diagnostic methods and guidelines for management

BACKGROUND

Viral encephalitis is a medical emergency. The prognosis depends mainly on the pathogen and host immunologic state. Correct immediate diagnosis and introduction of symptomatic and specific therapy has a dramatic influence upon survival and reduces the extent of permanent brain injury.

METHODS

We searched the literature from 1966 to 2009. Recommendations were reached by consensus. Where there was lack of evidence but consensus was clear, we have stated our opinion as good practice points.

RECOMMENDATIONS

Diagnosis should be based on medical history and examination followed by CSF analysis for protein and glucose levels, cellular analysis, and identification of the pathogen by polymerase chain reaction amplification (recommendation level A) and serology (level B). Neuroimaging, preferably by MRI, is essential (level B). Lumbar puncture can follow neuroimaging when immediately available, but if this cannot be performed immediately, LP should be delayed only under unusual circumstances. Brain biopsy should be reserved only for unusual and diagnostically difficult cases. Patients must be hospitalized with easy access to intensive care units. Specific, evidence-based, antiviral therapy, acyclovir, is available for herpes encephalitis (level A) and may also be effective for varicella-zoster virus encephalitis. Ganciclovir and foscarnet can be given to treat cytomegalovirus encephalitis, and pleconaril for enterovirus encephalitis (IV class evidence). Corticosteroids as an adjunct treatment for acute viral encephalitis are not generally considered to be effective, and their use is controversial, but this important issue is currently being evaluated in a large clinical trial. Surgical decompression is indicated for impending uncal herniation or increased intracranial pressure refractory to medical management.

Clinical vigilance for progressive multifocal leukoencephalopathy in the context of natalizumab use

Natalizumab therapy for patients with multiple sclerosis (MS) has been associated with both improved clinical outcomes and an increased incidence of progressive multifocal leukoencephalopathy (PML). We provide details of the etiology and recent history of PML as associated with immunosuppressive disease states, including MS. Furthermore, it offers clinical guidance on differentiating PML from a MS relapse and a review of the current treatment options for patients suspected of having developed the complication.

Progressive multifocal leukoencephalopathy in HIV-1 infection

Progressive multifocal leukoencephalopathy is caused by the JC polyomavirus (JCV) and is one of the most feared complications of HIV-1 infection. Unlike other opportunistic infections, this disease can present when CD4 counts are higher than those associated with AIDS and when patients are receiving combined antiretroviral therapy, either shortly after starting or, more rarely, during long term successful treatment. Clinical suspicion of the disease is typically when MRI shows focal neurological deficits and associated demyelinating lesions; however, the identification of JCV in cerebrospinal fluid or brain tissue is needed for a definitive diagnosis. Although no specific treatment exists, the reversal of immunosuppression by combined antiretroviral therapy leads to clinical and MRI stabilisation in 50-60% of patients with the disease, and JCV clearance from cerebrospinal fluid. A substantial proportion of patients treated with combined antiretroviral therapy develop inflammatory lesions, which can be associated with either a favourable outcome or clinical worsening. The reasons for variability in the natural history of progressive multifocal leukoencephalopathy and treatment responses are largely undefined, and more specific and rational approaches to management are needed.

Progressive Multifocal Leukoencephalopathy in HIV-Infected Children: A Case Report and Literature Review

We report a case of a perinatally HIV-infected patient aged 9 years, who presented with right-sided hemiplegia. His initial CD4 T-cell was of 0.21% (4 cells/μL) and plasma HIV RNA virus of 185 976 copies/mL (log 5.27). Plasma and CSF samples were subsequently positive for JCV. Twelve days after the initiation of highly active antiretroviral therapy (HAART), the MRI showed progressive white matter lesions with asymmetrical deep and subcortical white matter lesions over the left frontotemporoparietal region and the right frontal lobe. Immune Reconstitution Inflammatory Syndrome (IRIS) was suspected, and the patient was treated with methylprednisolone. His clinical symptoms worsened and despite therapy the patient deteriorated.

Treatment options for AIDS patients with progressive multifocal leukoencephalopathy

Progressive multifocal leukoencephalopathy (PML) is a demyelinating viral disease produced by the John Cunningham (JC) virus, which is ubiquitously distributed. Up to 80% of adults seroconvert to JC virus. Classically, PML is a life-threatening AIDS-defining disease of the CNS, usually occurring in severely immunocompromised individuals. Until now, and despite several therapeutic attempts, there is no specific treatment for PML. Soon after the widespread use of combination antiretroviral therapy (CART), several studies showed prolonged survival for patients with AIDS-associated PML who were treated with CART. The outcome of PML in patients receiving CART is unpredictable at disease onset. Prognostic markers are needed. The JC virus DNA detection in cerebrospinal fluid by nucleic acid amplification techniques and the CD4+ cell count are the most promising parameters. Higher levels of CD4+ cell counts were independently associated with an improved survival in different clinical observations. A summary of the main current knowledge about AIDS-related PML is presented. The most effective strategy is to optimize CART to completely suppress HIV-1 viral load and allow the best CD4+ T-cell immune recovery. Nowadays, AIDS-related PML is no longer an ultimately fatal disease. A substantial number of HIV-1-infected patients with this condition can improve with CART.

PML-IRIS in patients with HIV infection: clinical manifestations and treatment with steroids

BACKGROUND

Progressive multifocal leukoencephalopathy (PML) is an opportunistic infection that develops in immunosuppressed patients with HIV infection. Paradoxically, some of these patients may develop PML during combined antiretroviral therapy in the setting of immune reconstitution. We describe the types of PML in relation to immune reconstitution inflammatory syndrome (IRIS) and the effects of steroid use in these patients.

METHODS

We performed a retrospective review of the literature (1998 to 2007) and of all HIV-infected patients diagnosed with PML-IRIS at Johns Hopkins Hospital (2004 to 2007). We recorded information on clinical features, microbiologic and virological analysis, neuroimaging, pathology, treatment, and outcome.

RESULTS

Of 54 patients with PML-IRIS, 36 developed PML and IRIS simultaneously (PML-s-IRIS) and 18 had worsening of preexisting PML (PML-d-IRIS) after the initiation of combined antiretroviral therapy. PML-IRIS developed between 1 week and 26 months after initiation of antiretroviral therapy. PML-d-IRIS patients developed IRIS earlier, had higher lesion loads on MRI of the brain, had shorter durations of survival, and had higher mortality rate compared to PML-s-IRIS patients. Twelve patients received treatment with steroids, of which five died and seven showed good neurologic recovery. Patients who survived had received steroids early after IRIS diagnosis for longer durations and had contrast enhancement on IRIS neuroimaging.

CONCLUSIONS

Immune reconstitution following initiation of combined antiretroviral therapy may lead to activation of an inflammatory response to detectable or latent JC virus infection. Early and prolonged treatment with steroids may be useful in these patients but requires further investigation.

Acute disseminated encephalomyelitis: clinical and pathogenesis features

Acute disseminated encephalomyelitis (ADEM) is an immune-mediated disorder of the central nervous system (CNS). Disease typically starts with an abrupt onset of neurologic symptoms and signs within days to weeks after a viral infection or immunization. Neuropathological examination of the CNS in ADEM reveals involvement of white matter, with infiltration of monocytoid cells and perivenous demyelination.

[Treatment of opportunistic infections in adolescent and adult patients infected with the human immunodeficiency virus during the era of highly active antiretroviral therapy. AIDS Study Group (GESIDA) and National AIDS Plan Expert Committee]

Despite the huge advance that highly active antiretroviral therapy has represented for the prognosis of infection by human immunodeficiency virus (HIV), opportunistic infections continue to be a cause of morbidity and mortality in HIV-infected patients. This is often the case because of severe immunodepression, poor adherence to antiretroviral therapy, failure of therapy, or the fact that patients are unaware of their HIV-positive status and debut with an opportunistic infection. This article updates the guidelines on treatment of acute episodes of various opportunistic infections in HIV-infected patients, including infections due to parasites, fungi, viruses, mycobacteria, and bacteria. This edition has a new chapter on imported parasite infections as well as additional information on endemic mycoses in the chapter on fungal infections, taking into account the growing number of immigrants in our setting. Lastly, the chapter on the immune reconstitution syndrome has also been updated, providing relevant data on a phenomenon that has clinical and diagnostic repercussions in patients who start antiretroviral therapy while they are severely immunodepressed (English version available at http://www.gesida.seimc.org).

Influence of HAART on the clinical course of HIV-1-infected patients with progressive multifocal leukoencephalopathy: results of an observational multicenter study

BACKGROUND

The aim of this study was to analyze the incidence of new cases, survival of HIV-1-infected patients with progressive multifocal leukoencephalopathy (PML), and the characteristics of PML-associated immune reconstitution inflammatory syndrome (IRIS).

METHODS

Multicenter observational cohort study of all HIV-1-infected patients newly diagnosed of PML in 7 hospitals in Barcelona (Spain) from 2002 to 2006. The annual incidence of PML was calculated. Survival was estimated using the Kaplan-Meier method. IRIS was defined as new onset or rapid worsening of PML shortly after initiation of highly active antiretroviral therapy together with a decline in HIV-1 viral load and rising of CD4 lymphocytes.

RESULTS

Sixty-one new cases of PML were diagnosed. The mean survival time was 15 months [95% confidence interval (CI), 11 to 19]. The Kaplan-Meier estimates of the probability of survival were 47.7% (95% CI, 35 to 59) at 6 months, 38.6% (95% CI, 25 to 51) at 12 months, 35.1% (95% CI, 22 to 48) at 24 months, and 25.1% (95% CI, 10 to 40) at 36 months. IRIS was diagnosed in 14 (23%) cases. Mortality was similar in patients with and without IRIS.

CONCLUSIONS

PML continues to be one of the deadliest opportunistic infections in acquired immunodeficiency syndrome patients. The development of PML-associated IRIS has no influence on prognosis.

Laryngeal electromyography findings in a patient with HIV, John Cunningham virus and bilateral true vocal fold motion impairment

We present the findings from laryngeal electromyography (EMG) on a 33-year-old HIV-positive male who presented with decreased vocal endurance and a breathy voice. Management considerations were broadened by the history of John Cunningham (JC) virus recovered from his cerebrospinal fluid and the consequent diagnosis of progressive multifocal leukoencephalopathy. We reviewed the available literature on neuropathy, HIV, JC virus and how all these factors relate to voice disturbances. We present laryngeal EMG findings, discuss the benefit of electrodiagnostic studies, and offer an algorithm for interpreting this information and applying it to create the optimal care plan for these patients. As medical management of HIV-related diseases continues to improve, more patients may present with similar circumstances.

Disseminated sporotrichosis presenting with granulomatous inflammatory multiple mononeuropathies

We describe a case of sporotrichosis that disseminated to involve multiple nerves after initiation of immunosuppressive therapy and then precipitously worsened after withdrawal of therapy. This case illustrates that multiple mononeuropathies are not always caused by vasculitis, and a correct pathological diagnosis should be established before treatment. Based on clinical and pathological features, the mechanism of neuropathy may have been due to either direct nerve infection or a bystander effect of inflammatory/immune damage or, perhaps more likely, to both mechanisms.

Immune reconstitution inflammatory syndrome associated with progressive multifocal leukoencephalopathy in a perinatally acquired human immunodeficiency virus-infected young adult

Perinatally infected children represent a large proportion of the youth living with human immunodeficiency virusinfection/acquired immunodeficiency syndrome (HIV/AIDS). Because of nonadherence to treatment, an increasing number of perinatally acquired HIV-infected adolescents and young adults are showing virologic failure and immune suppression. We report a case of progressive multifocal leukoencephalopathy secondary to immune reconstitution inflammatory syndrome in a perinatally HIV-infected young adult, occurred shortly after the revision of an antiretroviral regimen. The patient showed marked improvement with the combination of corticosteroid and antiretroviral treatment.