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Kuruvada KM, DiFranza L, Fisher M. AKI in a Patient with Treated HIV Infection. KIDNEY360 2024; 5:1065-1066. [PMID: 39052475 PMCID: PMC11296535 DOI: 10.34067/kid.0000000000000480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Affiliation(s)
| | - Lanny DiFranza
- Department of Pathology, Albert Einstein College of Medicine, Bronx, New York
| | - Molly Fisher
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
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2
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Ellis J, Nsangi L, Bangdiwala A, Hale G, Gakuru J, Kagimu E, Mugabi T, Kigozi E, Tukundane A, Okirwoth M, Kandole TK, Cresswel F, Harrison TS, Moore D, Fielding K, Meya D, Boulware D, Jarvis JN. Integrated management of cryptococcal meningitis and concurrent opportunistic infections to improve outcomes in advanced HIV disease: a randomised strategy trial. Wellcome Open Res 2024; 9:14. [PMID: 38854693 PMCID: PMC11157187 DOI: 10.12688/wellcomeopenres.19324.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2024] [Indexed: 06/11/2024] Open
Abstract
Background Mortality associated with HIV-associated cryptococcal meningitis remains high even in the context of clinical trials (24-45% at 10 weeks); mortality at 12-months is up to 78% in resource limited settings. Co-prevalent tuberculosis (TB) is common and preventable, and likely contributes to poor patient outcomes. Innovative strategies to increase TB preventative therapy (TPT) provision and uptake within this high-risk group are needed. Protocol The IMPROVE trial (Integrated management of cryptococcal meningitis and concurrent opportunistic infections to improve outcomes in advanced HIV disease) is a nested open label, two arm, randomised controlled strategy trial to evaluate the safety (adverse events) and feasibility (adherence and tolerability) of two ultra-short course TPT strategies, in the context of recent diagnosis and treatment for cryptococcal meningitis. We will enrol 205 adults with HIV-associated cryptococcal meningitis from three hospitals in Uganda. Participants will be randomised to either inpatient initiation (early) or outpatient initiation (standard, week 6) of 1HP (one month of isoniazid and rifapentine). Participant follow-up is to include TB screening, 1HP pill counts and tolerability reviews on alternate weeks until week-18. The trial primary endpoint is TB-disease free 1HP treatment completion at 18-weeks, secondary endpoints: 1HP treatment completion, 1HP discontinuation, grade ≥3 adverse events and serious adverse events, drug-induced liver injury, incident active TB, 18-week survival; rifapentine, fluconazole and dolutegravir concentrations will be measured with intensive sampling in a pharmacokinetic sub-study of 15 eligible participants. Discussion The IMPROVE trial will provide preliminary safety and feasibility data to inform 1HP TPT strategies for adults with advanced HIV disease and cryptococcal meningitis. The potential impact of demonstrating that inpatient initiation of 1HP TPT is safe and feasible amongst this high-risk subpopulation with advanced HIV disease, would be to expand the range of clinical encounters in which clinicians can feasibly provide 1HP, and therefore increase the reach of TPT as a preventative intervention. ISRCTN registration ISRCTN18437550 (05/11/2021).
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Affiliation(s)
- Jayne Ellis
- College of Health Sciences, Makerere University, Infectious Diseases Institute, Kampala, Uganda
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Laura Nsangi
- College of Health Sciences, Makerere University, Infectious Diseases Institute, Kampala, Uganda
| | | | - Gila Hale
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Jane Gakuru
- College of Health Sciences, Makerere University, Infectious Diseases Institute, Kampala, Uganda
| | - Enock Kagimu
- College of Health Sciences, Makerere University, Infectious Diseases Institute, Kampala, Uganda
| | - Timothy Mugabi
- College of Health Sciences, Makerere University, Infectious Diseases Institute, Kampala, Uganda
| | - Enos Kigozi
- College of Health Sciences, Makerere University, Infectious Diseases Institute, Kampala, Uganda
| | - Asmus Tukundane
- College of Health Sciences, Makerere University, Infectious Diseases Institute, Kampala, Uganda
| | - Michael Okirwoth
- College of Health Sciences, Makerere University, Infectious Diseases Institute, Kampala, Uganda
| | - Tadeo Kiiza Kandole
- College of Health Sciences, Makerere University, Infectious Diseases Institute, Kampala, Uganda
| | - Fiona Cresswel
- College of Health Sciences, Makerere University, Infectious Diseases Institute, Kampala, Uganda
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Thomas S. Harrison
- MRC Centre for Medical Mycology, University of Exeter, Exeter, England, UK
- Centre for Global Health, Institute for Infection and Immunity, St George's University of London, London, UK
| | - David Moore
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Katherine Fielding
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - David Meya
- College of Health Sciences, Makerere University, Infectious Diseases Institute, Kampala, Uganda
| | - David Boulware
- University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
| | - Joseph N. Jarvis
- College of Health Sciences, Makerere University, Infectious Diseases Institute, Kampala, Uganda
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
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3
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Musubire A, Kagimu E, Mugabi T, Meya DB, Boulware DR, Bahr NC. Complex Decisions in HIV-Related Cryptococcosis: Addressing Second Episodes of Cryptococcal Meningitis. Curr HIV/AIDS Rep 2024; 21:75-85. [PMID: 38400871 PMCID: PMC11016006 DOI: 10.1007/s11904-024-00691-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2024] [Indexed: 02/26/2024]
Abstract
PURPOSE OF REVIEW This review highlights the difficulties in diagnosing and treating persons with a prior history of cryptococcal meningitis who improve but suffer from a recurrence of symptoms. This scenario is well known to those who frequently care for patients with cryptococcal meningitis but is not well understood. We highlight major gaps in knowledge. RECENT FINDINGS We recently summarized our experience with 28 persons with paradoxical immune reconstitution inflammatory syndrome (IRIS) and 81 persons with microbiological relapse. CD4 count and cerebrospinal fluid white blood cell count were higher in IRIS than relapse but neither was reliable enough to routinely differentiate these conditions. Second-episode cryptococcal meningitis remains a difficult clinical scenario as cryptococcal antigen, while excellent for initial diagnosis has no value in differentiating relapse of infection from other causes of recurrent symptoms. Updated research definitions are proposed and rapid, accurate diagnostic tests are urgently needed.
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Affiliation(s)
- Abdu Musubire
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Enock Kagimu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Timothy Mugabi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, 66160 KS, USA.
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4
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Le X, Shen Y. Advances in Antiretroviral Therapy for Patients with Human Immunodeficiency Virus-Associated Tuberculosis. Viruses 2024; 16:494. [PMID: 38675837 PMCID: PMC11054420 DOI: 10.3390/v16040494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/09/2024] [Accepted: 03/22/2024] [Indexed: 04/28/2024] Open
Abstract
Tuberculosis is one of the most common opportunistic infections and a prominent cause of death in patients with human immunodeficiency virus (HIV) infection, in spite of near-universal access to antiretroviral therapy (ART) and tuberculosis preventive therapy. For patients with active tuberculosis but not yet receiving ART, starting ART after anti-tuberculosis treatment can complicate clinical management due to drug toxicities, drug-drug interactions and immune reconstitution inflammatory syndrome (IRIS) events. The timing of ART initiation has a crucial impact on treatment outcomes, especially for patients with tuberculous meningitis. The principles of ART in patients with HIV-associated tuberculosis are specific and relatively complex in comparison to patients with other opportunistic infections or cancers. In this review, we summarize the current progress in the timing of ART initiation, ART regimens, drug-drug interactions between anti-tuberculosis and antiretroviral agents, and IRIS.
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Affiliation(s)
| | - Yinzhong Shen
- Department of Infection and Immunity, Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China;
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5
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Kalita J, Shukla R, Pandey PC, Singh V, Haldar R, Misra UK. mRNA profiling of cytokines to understand paradoxical response in HIV-uninfected tuberculous meningitis. Tuberculosis (Edinb) 2024; 144:102463. [PMID: 38101267 DOI: 10.1016/j.tube.2023.102463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/29/2023] [Accepted: 12/05/2023] [Indexed: 12/17/2023]
Abstract
Paradoxical reaction (PR) in tuberculous meningitis (TBM) is a major management issue. We report mRNA profiling of cytokines to understand PR in HIV-uninfected TBM patients. 72 patients with TBM were included, and their clinical, MRI, and mRNA profiling of tumor necrosis factor (TNF) α, interleukin (IL) 6, IL10 and interferon (IFN) γ genes in the peripheral blood mononuclear cells were done at admission and 6 weeks of antitubercular treatment. Cytokine profiling was done using reverse transcriptase polymerase chain reaction. PR was defined if repeat MRI at 6 weeks revealed new or increase in exudates, tuberculoma, hydrocephalus or infarctions. Outcome was defined at 6 months using modified Rankin Scale (mRS), and categorized as death, poor and good. 44 (61.1 %) patients had PR, and 28 (38.9 %) had paradoxical tuberculoma (PT). The expression of IL6 and TNFα genes were higher in PR and PT groups. Stage of meningitis and hydrocephalus at admission predicted PR. Patients with PR and PT had more frequently poor outcome. About three-fifth HIV-uninfected TBM patients have PR and two-fifth have PT. Paradoxical reaction is associated with higher expression of IL6 and TNFα. Patients with severe meningitis with hydrocephalus develop PR more frequently.
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Affiliation(s)
- Jayantee Kalita
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, Uttar Pradesh, India.
| | - Ruchi Shukla
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, Uttar Pradesh, India
| | - Prakash C Pandey
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, Uttar Pradesh, India
| | - Vivek Singh
- Department of Radio diagnosis Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, Uttar Pradesh, India
| | - Rudrashish Haldar
- Department of Anesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, Uttar Pradesh, India
| | - Usha K Misra
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, Uttar Pradesh, India
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Tugume L, Semitala FC, Owachi D, Kagimu E, Kamya MR, Meya DB. Clinical characteristics and morbidity among hospitalized adults with advanced HIV disease in Uganda during 'test and treat' era. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002457. [PMID: 37851597 PMCID: PMC10584089 DOI: 10.1371/journal.pgph.0002457] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 09/13/2023] [Indexed: 10/20/2023]
Abstract
Nearly four decades after the first case of AIDS was described, the global number of AIDS-related deaths has steadily declined but falls short of the elimination targets, especially in sub-Saharan Africa. Despite interventions to promote early HIV diagnosis and treatment, hospitalization and mortality related to advanced HIV disease (AHD) remains a significant public health problem in Uganda. We assessed the HIV treatment history and causes of hospitalization among in-patients with AHD at a tertiary hospital in Uganda. In this cross-sectional study, pre-hospitalization HIV treatment history and clinical characteristics of HIV-positive in-patients with CD4<200 cells/μL or WHO stage 3 or 4 clinical events were assessed. Descriptive data were summarized using percentages and medians. Among hospitalized adults with AHD from November 2021 to June 2022, 74% (260/353) knew their HIV status prior to hospitalization and 62% (219/353) were ART experienced at presentation. The median time since ART initiation was 28 months (IQR; 2-97). Overall, 73% (258/353) had at least two etiological diagnoses and the majority (non-mutually exclusive) were diagnosed with tuberculosis (61.2%), cryptococcal meningitis (20.7%), mucosal candidiasis (16.1%) and bacterial infections (15%). In conclusion, nearly two-thirds of in-patients with advanced HIV disease were ART experienced prior to hospitalization and tuberculosis was the most common cause of hospitalization. Innovative strategies to strengthen HIV diagnosis, linkage, and retention in HIV care and to increase coverage of TB preventive therapy are urgently needed.
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Affiliation(s)
- Lillian Tugume
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Fred C. Semitala
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Kiruddu National Referral Hospital, Kampala, Uganda
- Makerere University Joint AIDS Program, Kampala, Uganda
| | | | - Enock Kagimu
- Department of Research, Infectious Diseases Institute Makerere University, Kampala, Uganda
| | - Moses R. Kamya
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - David B. Meya
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Department of Research, Infectious Diseases Institute Makerere University, Kampala, Uganda
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Kitenge MK, Fatti G, Eshun-Wilson I, Aluko O, Nyasulu P. Prevalence and trends of advanced HIV disease among antiretroviral therapy-naïve and antiretroviral therapy-experienced patients in South Africa between 2010-2021: a systematic review and meta-analysis. BMC Infect Dis 2023; 23:549. [PMID: 37608300 PMCID: PMC10464046 DOI: 10.1186/s12879-023-08521-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 08/08/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Despite the significant progress made in South Africa in getting millions of individuals living with HIV into care, many patients still present or re-enter care with Advanced HIV Disease (AHD). We aimed to estimate the prevalence of AHD among ART-naive and ART-experienced patients in South Africa using studies published between January 2010 and May 2022. METHODS We searched for relevant data on PubMed, CINAHL, Scopus and other sources, with a geographical filters limited to South Africa, up to May 31, 2022. Two reviewers conducted all screening, eligibility assessment, data extraction, and critical appraisal. We synthesized the data using the inverse-variance heterogeneity model and Freeman-Tukey transformation. We assessed heterogeneity using the I2 statistic and publication bias using the Egger and Begg's test. RESULTS We identified 2,496 records, of which 53 met the eligibility criteria, involving 11,545,460 individuals. The pooled prevalence of AHD among ART-naive and ART-experienced patients was 43.45% (95% CI 40.1-46.8%, n = 53 studies) and 58.6% (95% CI 55.7 to 61.5%, n = 2) respectively. The time trend analysis showed a decline of 2% in the prevalence of AHD among ART-naive patients per year. However, given the high heterogeneity between studies, the pooled prevalence should be interpreted with caution. CONCLUSION Despite HIV's evolution to a chronic disease, our findings show that the burden of AHD remains high among both ART-naive and ART-experienced patients in South Africa. This emphasizes the importance of regular measurement of CD4 cell count as an essential component of HIV care. In addition, providing innovative adherence support and interventions to retain ART patients in effective care is a crucial priority for those on ART.
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Affiliation(s)
- Marcel K Kitenge
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
- Tuberculosis and HIV investigative Network (THINK), Durban, Kwazulu-Natal, South Africa.
| | - Geoffrey Fatti
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Kheth'Impilo AIDS Free Living, Cape Town, South Africa
| | - Ingrid Eshun-Wilson
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Infectious Diseases, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Omololu Aluko
- Faculty of Health Sciences, School of Medical Sciences, Department of Biostatistics, University of the Free State, Bloemfontein, South Africa
| | - Peter Nyasulu
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Geteneh A, Andualem H, Belay DM, Kiros M, Biset S. Immune reconstitution inflammatory syndrome, a controversial burden in the East African context: a systematic review and meta-analysis. Front Med (Lausanne) 2023; 10:1192086. [PMID: 37636563 PMCID: PMC10450628 DOI: 10.3389/fmed.2023.1192086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/18/2023] [Indexed: 08/29/2023] Open
Abstract
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.
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Affiliation(s)
- Alene Geteneh
- Department of Medical Laboratory Science, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Henok Andualem
- Department of Medical Laboratory Science, College of Medicine and Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Demeke Mesfin Belay
- Department of Pediatrics and Child Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Mulugeta Kiros
- Department of Medical Laboratory Science, College of Medicine and Health Sciences, Aksum University, Aksum, Ethiopia
| | - Sirak Biset
- Department of Medical Microbiology, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Lamrous A, Repetto E, Depp T, Jimenez C, Chua AC, Kanapathipillai R, Jensen TO. C-reactive protein and procalcitonin use in adults in low- and middle-income countries: a narrative review. JAC Antimicrob Resist 2023; 5:dlad057. [PMID: 37206308 PMCID: PMC10190046 DOI: 10.1093/jacamr/dlad057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023] Open
Abstract
Objectives C-reactive protein (CRP) and procalcitonin (PCT) are widely used biomarkers in high-income countries. However, evidence for their use in low- and middle-income countries (LMICs) is scant. Because many factors, including rates of endemic disease, comorbidities and genetics, may influence biomarkers' behaviour, we aimed to review available evidence generated in LMICs. Methods We searched the PubMed database for relevant studies within the last 20 years that originated in regions of interest (Africa, Latin America, Middle East, South Asia or South East Asia), and full-text articles involving diagnosis, prognostication and evaluation of therapeutic response with CRP and/or PCT in adults (n = 88) were reviewed and categorized in 12 predefined focus areas. Results Overall, results were highly heterogeneous, at times conflicting, and often lacking clinically useful cut-off values. However, most studies demonstrated higher levels of CRP/PCT in patients with bacterial versus other infections. HIV and TB patients had consistently higher levels of CRP/PCT versus controls. In addition, higher CRP/PCT levels at baseline and follow-up in HIV, TB, sepsis and respiratory tract infections were associated with poorer prognosis. Conclusions Evidence generated from LMIC cohorts suggests that CRP and PCT may have potential to become effective clinical guiding tools particularly in respiratory tract infections, sepsis and HIV/TB. However, more studies are needed to define potential scenarios for use and cost-effectiveness. Consensus across stakeholders regarding target conditions, laboratory standards and cut-off values would support the quality and applicability of future evidence.
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Affiliation(s)
- Amin Lamrous
- Médecins Sans Frontières, Operational Center Barcelona, Barcelona, Spain
| | - Ernestina Repetto
- Médecins Sans Frontières, Operational Center Geneva, Geneva, Switzerland
- Infectious Diseases Department, Université Libre de Bruxelles (ULB), CHU Saint-Pierre, Brussels, Belgium
| | - Tim Depp
- Emergency Medicine, University of South Carolina School of Medicine, Greenville, SC, USA
| | - Carolina Jimenez
- Médecins Sans Frontières, Operational Center Paris, Paris, France
| | - Arlene C Chua
- Medical Department, Médecins Sans Frontières—International, Geneva, Switzerland
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Tuberculosis-Associated Immune Reconstitution Inflammatory Syndrome-An Extempore Game of Misfiring with Defense Arsenals. Pathogens 2023; 12:pathogens12020210. [PMID: 36839482 PMCID: PMC9964757 DOI: 10.3390/pathogens12020210] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 01/21/2023] [Accepted: 01/28/2023] [Indexed: 01/31/2023] Open
Abstract
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.
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Alemu GG, Nigussie ZM, Amlak BT, Achamyeleh AA. Survival time and predictors of death among HIV infected under five children after initiation of anti -retroviral therapy in West Amhara Referral Hospitals, Northwest Ethiopia. BMC Pediatr 2022; 22:670. [PMID: 36411424 PMCID: PMC9677693 DOI: 10.1186/s12887-022-03693-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 09/05/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Acquired immune deficiency syndrome is an infectious disease caused by the human immunodeficiency virus (HIV) that primarily targets an individual's immune system. In Ethiopia, nearly 24% of HIV-related deaths occur in children under the age of five. However, studies regarding the survival time of HIV-positive under-five children after anti-retroviral therapy initiation are limited with poor evidence of predictors of death. OBJECTIVE To assess survival time and predictors of death among HIV infected under-five children after initiation of anti-retroviral therapy in West Amhara Referral Hospitals, Northwest Ethiopia, 2021. METHODS A multicenter institution-based retrospective follow-up study was conducted among 432 HIV-positive under-five children on anti-retroviral therapy selected by simple random sampling from January 2010 to December 2019. A standardized data extraction tool was employed, which was adapted from anti-retroviral therapy entry and follow-up forms. The event of interest for this study is death, whereas the absence of experience of death is censored. Data were entered into Epi-Data version 3.1 and exported to STATA version 14. The Kaplan-Meier curve was used to estimate the survival probability. The Cox regression model was used to identify independent predictors of death. RESULTS Among the 415 records included in the final analysis, 25 (6.02%) of the individuals were died. The incidence rate of death was found to be 2.87 per 1000 child-months (95%CI: 1.94-4.25). The cumulative survival probabilities of children after 6, 12, 24, and 36 months were 0.97, 0.95, 0.92, and 0.85 respectively. HIV-infected under-five children who lived in rural areas (AHR 3.32:-95% CI 1.17-9.39), with poor adherence to anti-retroviral therapy (AHR = 3.36; CI: 1.06, 10.69), without Isoniazide prophylaxis (AHR = 3.15; CI: 1.11, 8.94) and with anemia (AHR: 3.05, 95% CI: 1.16, 8.03) were at higher risk of death. CONCLUSION AND RECOMMENDATION Death of HIV-infected under-five children on anti-retroviral therapy is high within the first one year after enrolment. Living in rural area, had poor adherence, lacked Isoniazide prophylaxis, and anemia were predictors of death. Therefore, clinicians shall emphasize for those specific risk factors of death and take action accordingly.
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Affiliation(s)
- Gebrie Getu Alemu
- Department of Nursing, Bahir Dar Health Science College, Bahir Dar, Ethiopia
| | - Zelalem Mehari Nigussie
- Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Baye Tsegaye Amlak
- College of Health Sciences, Department of Nursing, Debre Markos University, Debre Markos, Ethiopia
| | - Anemaw Asrat Achamyeleh
- Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
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12
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Byers BW, Drak D, Shamu T, Chimbetete C, Dahwa R, Gracey DM. Comparison of predictors for early and late mortality in adults commencing HIV antiretroviral therapy in Zimbabwe: a retrospective cohort study. AIDS Res Ther 2022; 19:23. [PMID: 35643492 PMCID: PMC9148446 DOI: 10.1186/s12981-022-00445-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 04/26/2022] [Indexed: 11/28/2022] Open
Abstract
Background People living with HIV (PLWHIV) commencing antiretroviral therapy (ART) in sub-Saharan Africa experience significant mortality within the first year. Previously, identified risk factors for mortality may be biased towards these patients, as compared to those who experience late mortality. Aim To compare risk factors for early and late mortality in PLWHIV commencing ART. Methods A retrospective cohort study of ART-naïve patients aged ≥ 18 years from an outpatient HIV clinic in Zimbabwe. Data were collected between January 2010 and January 2019. Predictors for early (≤ 1 year) and late mortality (> 1 year) were determined by multivariable cox proportional hazards analyses, with patients censored at 1 year and landmark analysis after 1 year, respectively. Results Three thousand and thirty-nine PLWHIV were included in the analysis. Over a median follow-up of 4.6 years (IQR 2.5–6.9), there was a mortality rate of 8.8%, with 50.4% of deaths occurring within 1 year. Predictors of early mortality included CD4 count < 50 cells/µL (HR 1.84, 95% CI 1.24–2.72, p < 0.01), WHO Stage III (HR 2.05, 95% CI 1.28–3.27, p < 0.01) or IV (HR 2.83, 95% CI 1.67–4.81, p < 0.01), and eGFR < 90 mL/min/1.73 m2 (HR 2.48, 95% CI 1.56–3.96, p < 0.01). Other than age (p < 0.01), only proteinuria (HR 2.12, 95% CI 1.12–4.01, p = 0.02) and diabetes mellitus (HR 3.51, 95% CI 1.32–9.32, p = 0.01) were associated with increased risk of late mortality. Conclusions
Traditional markers of mortality risk in patients commencing ART appear to be limited to early mortality. Proteinuria and diabetes are some of the few predictors of late mortality, and should be incorporated into routine screening of patients commencing ART.
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Petrakis V, Panagopoulos P, Vrachiolias G, Spanoudakis E, Papazoglou D, Kotsianidis I, Liapis K. Onionskin-like histiocytes in an HIV late presenter. QJM 2022; 115:312-313. [PMID: 35325246 DOI: 10.1093/qjmed/hcac082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - P Panagopoulos
- Department of Infectious Diseases, Second University Department of Internal Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, Dragana Area, Alexandroupolis 681 00, Greece
| | - G Vrachiolias
- Department of Hematology, University Hospital of Alexandroupolis, Democritus University of Thrace, Dragana Area, Alexandroupolis 681 00, Greece
| | - E Spanoudakis
- Department of Hematology, University Hospital of Alexandroupolis, Democritus University of Thrace, Dragana Area, Alexandroupolis 681 00, Greece
| | - D Papazoglou
- Department of Infectious Diseases, Second University Department of Internal Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace , Dragana Area, Alexandroupolis 681 00, Greece
| | - I Kotsianidis
- Department of Hematology, University Hospital of Alexandroupolis , Democritus University of Thrace, Dragana Area, Alexandroupolis 681 00, Greece
| | - K Liapis
- Department of Hematology, University Hospital of Alexandroupolis , Democritus University of Thrace, Dragana Area, Alexandroupolis 681 00, Greece
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Makhoul J, Uppal S, Siegel M. Double Trouble: Concomitant Unmasking and Paradoxical Immune Reconstitution Inflammatory Syndrome in a Patient with Newly Diagnosed HIV. IDCases 2022; 28:e01482. [PMID: 35392599 PMCID: PMC8980619 DOI: 10.1016/j.idcr.2022.e01482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/09/2022] [Accepted: 03/23/2022] [Indexed: 11/02/2022] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) is a complication encountered in patients with HIV due to immune function recovery following the initiation of antiretroviral therapy. IRIS can be divided into two forms: paradoxical (recurrence of clinical signs of a previously treated opportunistic infection) and unmasking (uncovering of a previously undiagnosed and asymptomatic infection). We present the rare case of a 48-year-old man diagnosed with AIDS after presenting with cryptococcal meningitis who, shortly after initiation of ART, developed both unmasking IRIS due to Mycobacterium avium complex (MAC), and subsequently paradoxical IRIS to his prior cryptococcal meningitis infection. To our knowledge, cases in the medical literature describing “double IRIS” remain scarce.
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15
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Poizot-Martin I, Brégigeon S, Palich R, Marcelin AG, Valantin MA, Solas C, Veyri M, Spano JP, Makinson A. Immune Reconstitution Inflammatory Syndrome Associated Kaposi Sarcoma. Cancers (Basel) 2022; 14:986. [PMID: 35205734 PMCID: PMC8869819 DOI: 10.3390/cancers14040986] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/28/2022] [Accepted: 02/09/2022] [Indexed: 02/01/2023] Open
Abstract
People living with HIV (PLWH) with advanced immunosuppression who initiate antiretroviral therapy (ART) are susceptible to the occurrence of an immune reconstitution inflammatory syndrome (IRIS). Although ART is responsible for AIDS- associated Kaposi sarcoma (KS) improvement and resolution, new onset (unmasking KS-IRIS) or sudden progression of preexisting KS (paradoxical KS-IRIS) can occur after a time delay of between a few days and 6 months after the initiation or resumption of ART, even in patients with a low degree of immunocompromise. KS-IRIS incidence varies from 2.4% to 39%, depending on study design, populations, and geographic regions. Risk factors for developing KS-IRIS include advanced KS tumor stage (T1), pre-treatment HIV viral load >5 log10 copies/mL, detectable pre-treatment plasma-KSHV, and initiation of ART alone without concurrent chemotherapy. Both paradoxical and unmasking KS-IRIS have been associated with significant morbidity and mortality, and thrombocytopenia (<100,000 platelets/mm3 at 12 weeks) has been associated with death. KS-IRIS is not to be considered as ART failure, and an ART regimen must be pursued. Systemic chemotherapy for KS in conjunction with ART is recommended and, in contrast with management of IRIS for other opportunistic infections, glucocorticoids are contra-indicated. Despite our preliminary results, the place of targeted therapies in the prevention or treatment of KS-IRIS needs further assessment.
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Affiliation(s)
- Isabelle Poizot-Martin
- Assistance Publique-Hôpitaux de Marseille (APHM), Inserm, Institut de Recherche pour le Développement (IRD), SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, ISSPAM, APHM Sainte-Marguerite, Service D’immuno-Hématologie Clinique, Aix-Marseille Université, 13009 Marseille, France
| | - Sylvie Brégigeon
- Assistance Publique-Hôpitaux de Marseille (APHM) Sainte-Marguerite, Service D’immuno-Hématologie Clinique, Aix-Marseille Université, 13009 Marseille, France;
| | - Romain Palich
- Department of Infectious Diseases, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Pierre Louis Epidemiology and Public Health Institute (iPLESP), INSERM U1136, Sorbonne University, 75013 Paris, France; (R.P.); (M.-A.V.)
| | - Anne-Geneviève Marcelin
- INSERM, Institut Pierre Louis d’Epidémiologie et de Santé Publique (iPLESP), AP-HP, Hôpital Pitié Salpêtrière, Service de Virologie, Sorbonne Université, 75013 Paris, France;
| | - Marc-Antoine Valantin
- Department of Infectious Diseases, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Pierre Louis Epidemiology and Public Health Institute (iPLESP), INSERM U1136, Sorbonne University, 75013 Paris, France; (R.P.); (M.-A.V.)
| | - Caroline Solas
- Assistance Publique-Hôpitaux de Marseille (APHM), Hôpital La Timone, Laboratoire de Pharmacocinétique et Toxicologie, INSERM 1207, IRD 190, Unité des Virus Emergents, Aix-Marseille Université, 13005 Marseille, France;
| | - Marianne Veyri
- Department of Medical Oncology, Pitié Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Institut Universitaire de Cancérologie (IUC), CLIP2 Galilée, Pierre Louis Epidemiology and Public Health Institute (iPLESP), INSERM U1136, Sorbonne Université, 75013 Paris, France; (M.V.); (J.-P.S.)
| | - Jean-Philippe Spano
- Department of Medical Oncology, Pitié Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Institut Universitaire de Cancérologie (IUC), CLIP2 Galilée, Pierre Louis Epidemiology and Public Health Institute (iPLESP), INSERM U1136, Sorbonne Université, 75013 Paris, France; (M.V.); (J.-P.S.)
| | - Alain Makinson
- Centre Hospitalier Universitaire de Montpellier, Département des Maladies Infectieuses et Tropicales, INSERM U1175/IRD UMI 233, 34000 Montpellier, France;
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16
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AIDS Related Kaposi's Sarcoma: A 20-Year Experience in a Clinic from the South-East of Romania. J Clin Med 2021; 10:jcm10225346. [PMID: 34830628 PMCID: PMC8620409 DOI: 10.3390/jcm10225346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/11/2021] [Accepted: 11/15/2021] [Indexed: 11/16/2022] Open
Abstract
Kaposi’s sarcoma (KS) was peculiarly described in the first notified cases of the acquired immunodeficiency syndrome as an opportunistic condition. However, the medical progress and the development of active antiretroviral therapy allowed the control of the HIV/AIDS epidemic, although the features of KS have changed throughout the past decades. The purpose of our study is to assess the epidemiological and clinical features of AIDS related KS in Romanian patients. A retrospective follow-up study was achieved in a single infectious diseases’ clinic from Galati—Romania, between 2001 and 2021. Referring to 290 new HIV diagnosed cases from our clinic retained in care, the prevalence of KS was 3.4%. The main characteristics of patients with KS are a median age of 33, a predominance of males, prevalent severe systemic forms of diseases, frequent association of past or concomitant tuberculosis, and context of immune reconstruction syndrome. The mortality rate was 70%. KS has occurred in patients with delayed HIV diagnoses and inadequate adherence to therapy. Early recognition of both infections, the close monitoring of latent or symptomatic tuberculosis, improving the antiretroviral adherence and raising the access to oncologic procedures in Romanian HIV patients could improve their prognosis related to KS.
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17
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Lawal IO, Orunmuyi AT, Popoola GO, Mokoala KMG, Lengana T, Sathekge MM. Immune reconstitution inflammatory syndrome-associated Graves disease in HIV-infected patients: clinical characteristics and response to radioactive iodine therapy. HIV Med 2021; 22:907-916. [PMID: 34328251 DOI: 10.1111/hiv.13148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 07/08/2021] [Indexed: 12/23/2022]
Abstract
OBJECTIVES We aimed to describe the clinical characteristics and the response to radioactive iodine (RAI) treatment of immune reconstitution inflammatory syndrome-associated Graves disease (IRIS-GD) in comparison to Graves disease (GD) seen in HIV-uninfected patients. METHODS We retrospectively reviewed the medical records of patients treated with RAI for GD. We obtained clinical, biochemical and HIV-related information of patients from their medical records. We compared patient characteristics and response to RAI treatment between patients with IRIS-GD and GD seen in HIV-uninfected patients. RESULTS A total of 253 GD patients, including 51 patients with IRIS-GD, were included. Among IRIS-GD patients, CD4 cell nadir was 66 cells/µL (range: 37-103) with a peak HIV viral load of 60 900 copies/mL (range: 36 542-64 500). At the time of diagnosis of IRIS-GD, all patients had a completely suppressed HIV viraemia with a CD4 cell count of 729 cells/µL (range: 350-1279). The median interval between the commencement of HIV treatment and the onset of GD was 63 months. At 3 months follow-up, the proportion of patients with IRIS-GD achieving a successful RAI treatment outcome (euthyroid/hypothyroid state) was lower than that of HIV-uninfected patients (35.3% vs. 63.4%, respectively; p < 0.001). The response rate remained lower (60.8%) among patients with IRIS GD than among HIV-uninfected GD patients (80.2%, p = 0.004) at 6 months follow-up. After correcting for differences in age, gender and pre-treatment thyroid-stimulating hormone level, there was no significant difference in RAI treatment response between the two groups. CONCLUSIONS After correcting for possible confounders, the response to RAI treatment was not different between patients with IRIS-GD and GD in HIV-uninfected patients.
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Affiliation(s)
- Ismaheel O Lawal
- Department of Nuclear Medicine, University of Pretoria & Steve Biko Academic Hospital, Pretoria, South Africa.,Nuclear Medicine Research Infrastructure (NuMeRI), Steve Biko Academic Hospital, Pretoria, South Africa
| | - Akintunde T Orunmuyi
- Department of Nuclear Medicine, University of Ibadan & University College Hospital, Ibadan, Nigeria
| | - Gbenga O Popoola
- Department of Epidemiology and Community Health, University of Ilorin, Ilorin, Nigeria
| | - Kgomotso M G Mokoala
- Department of Nuclear Medicine, University of Pretoria & Steve Biko Academic Hospital, Pretoria, South Africa.,Nuclear Medicine Research Infrastructure (NuMeRI), Steve Biko Academic Hospital, Pretoria, South Africa
| | - Thabo Lengana
- Department of Nuclear Medicine, University of Pretoria & Steve Biko Academic Hospital, Pretoria, South Africa
| | - Mike M Sathekge
- Department of Nuclear Medicine, University of Pretoria & Steve Biko Academic Hospital, Pretoria, South Africa.,Nuclear Medicine Research Infrastructure (NuMeRI), Steve Biko Academic Hospital, Pretoria, South Africa
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Cryptococcal Immune Reconstitution Inflammatory Syndrome: From Blood and Cerebrospinal Fluid Biomarkers to Treatment Approaches. Life (Basel) 2021; 11:life11020095. [PMID: 33514007 PMCID: PMC7912256 DOI: 10.3390/life11020095] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 01/20/2021] [Accepted: 01/23/2021] [Indexed: 12/31/2022] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) presents as an exaggerated immune reaction that occurs during dysregulated immune restoration in immunocompromised patients in late-stage human immunodeficiency virus (HIV) infection who have commenced antiretroviral treatments (ART). Virtually any opportunistic pathogen can provoke this type of immune restoration disorder. In this review, we focus on recent developments in the identification of risk factors for Cryptococcal IRIS and on advancements in our understanding of C-IRIS immunopathogenesis. We overview new findings in blood and cerebrospinal fluid which can potentially be useful in the prediction and diagnosis of cryptococcal meningitis IRIS (CM-IRIS). We assess current therapeutic regimens and novel treatment approaches to combat CM-IRIS. We discuss the utility of biomarkers for clinical monitoring and adjusting treatment modalities in acquired immunodeficiency syndrome (AIDS) patients co-infected with Cryptococcus who have initiated ART.
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19
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Castillejos-García I, Ramírez-Amador V, Gómez-Mejía E, Badial-Hernández F, Anaya-Saavedra G. Clinical manifestations and risk factors for oral immune reconstitution inflammatory syndrome in Mexico. Oral Dis 2020; 26 Suppl 1:153-157. [PMID: 32862543 DOI: 10.1111/odi.13402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The immune reconstitution inflammatory syndrome (IRIS) is a rare acute complication presenting in people living with HIV (PLWH) within the first 6 months of starting combined antiretroviral therapy (cART). While there is relevant information about its pathogenesis and clinical spectrum, IRIS-oral lesions (IRIS-OLs) have been scarcely described. Thus, to establish the incidence and clinical characteristics of IRIS-OLs, data from a cohort of 158 HIV individuals starting cART, followed for 6 months, were obtained retrospectively. IRIS-OLs developed in 11.4% of the individuals, in a median time of 87.5 days, with oral candidiasis being the most frequent manifestation detected in eight individuals (5.1%). The study emphasizes the importance of the correct diagnosis and management of these lesions.
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Affiliation(s)
- Itzel Castillejos-García
- Oral Pathology and Medicine Master, Universidad Autónoma Metropolitana-Xochimilco, Mexico City, Mexico
| | - Velia Ramírez-Amador
- Oral Pathology and Medicine Master, Universidad Autónoma Metropolitana-Xochimilco, Mexico City, Mexico
| | - Eduardo Gómez-Mejía
- Oral Pathology and Medicine Master, Universidad Autónoma Metropolitana-Xochimilco, Mexico City, Mexico
| | | | - Gabriela Anaya-Saavedra
- Oral Pathology and Medicine Master, Universidad Autónoma Metropolitana-Xochimilco, Mexico City, Mexico
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20
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Quinn CM, Poplin V, Kasibante J, Yuquimpo K, Gakuru J, Cresswell FV, Bahr NC. Tuberculosis IRIS: Pathogenesis, Presentation, and Management across the Spectrum of Disease. Life (Basel) 2020; 10:E262. [PMID: 33138069 PMCID: PMC7693460 DOI: 10.3390/life10110262] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 10/13/2020] [Accepted: 10/21/2020] [Indexed: 12/14/2022] Open
Abstract
Antiretroviral therapy (ART), while essential in combatting tuberculosis (TB) and HIV coinfection, is often complicated by the TB-associated immune reconstitution inflammatory syndrome (TB-IRIS). Depending on the TB disease site and treatment status at ART initiation, this immune-mediated worsening of TB pathology can take the form of paradoxical TB-IRIS, unmasking TB-IRIS, or CNS TB-IRIS. Each form of TB-IRIS has unique implications for diagnosis and treatment. Recently published studies have emphasized the importance of neutrophils and T cell subtypes in TB-IRIS pathogenesis, alongside the recognized role of CD4 T cells and macrophages. Research has also refined our prognostic understanding, revealing how the disease can impact lung function. While corticosteroids remain the only trial-supported therapy for prevention and management of TB-IRIS, increasing interest has been given to biologic therapies directly targeting the immune pathology. TB-IRIS, especially its unmasking form, remains incompletely described and more data is needed to validate biomarkers for diagnosis. Management strategies remain suboptimal, especially in the highly morbid central nervous system (CNS) form of the disease, and further trials are necessary to refine treatment. In this review we will summarize the current understanding of the immunopathogenesis, the presentation of TB-IRIS and the evidence for management recommendations.
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Affiliation(s)
- Carson M. Quinn
- School of Medicine, University of California, San Francisco, CA 94143, USA
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; (J.K.); (J.G.); (F.V.C.)
| | - Victoria Poplin
- Division of Infectious Diseases, Department of Medicine, University of Kansas, Kansas City, KS 66045, USA; (V.P.); (N.C.B.)
| | - John Kasibante
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; (J.K.); (J.G.); (F.V.C.)
| | - Kyle Yuquimpo
- Department of Medicine, University of Kansas, Kansas City, KS 66045, USA;
| | - Jane Gakuru
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; (J.K.); (J.G.); (F.V.C.)
| | - Fiona V. Cresswell
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; (J.K.); (J.G.); (F.V.C.)
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- Medical Research Council, Uganda Virus Research Unit, London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Nathan C. Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas, Kansas City, KS 66045, USA; (V.P.); (N.C.B.)
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21
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Narendran G, Jyotheeswaran K, Senguttuvan T, Vinhaes CL, Santhanakrishnan RK, Manoharan T, Selvaraj A, Chandrasekaran P, Menon PA, Bhavani KP, Reddy D, Narayanan R, Subramanyam B, Sathyavelu S, Krishnaraja R, Kalirajan P, Angamuthu D, Susaimuthu SM, Ganesan RRK, Tripathy SP, Swaminathan S, Andrade BB. Characteristics of paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome and its influence on tuberculosis treatment outcomes in persons living with HIV. Int J Infect Dis 2020; 98:261-267. [PMID: 32623087 DOI: 10.1016/j.ijid.2020.06.097] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/27/2020] [Accepted: 06/29/2020] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE The influence of tuberculosis (TB)-immune reconstitution inflammatory syndrome (IRIS) on TB treatment outcomes and its risk factors were investigated among people with human immunodeficiency virus (HIV) and co-infected with TB. METHODS Newly diagnosed, culture-confirmed, pulmonary TB patients with HIV and enrolled in a clinical trial (NCT00933790) were retrospectively analysed for IRIS occurrence. Risk factors and TB outcomes (up to 18 months after initiation of anti-TB treatment [ATT]) were compared between people who experienced IRIS (IRIS group) and those who did not (non-IRIS group). RESULTS TB-IRIS occurred in 82 of 292 (28%) participants. Significant baseline risk factors predisposing to TB-IRIS occurrence in univariate analysis were: lower CD4+ T-cell count, CD4/CD8 ratio, haemoglobin levels, presence of extra-pulmonary TB focus, and higher HIV viral load; the last two retained significance in the multivariate analysis. After 2 months of ATT commencement, sputum smear conversion was documented in 45 of 80 (56.2%) vs. 124 of 194 (63.9%) (p=0.23), culture conversion was in 75 of 80 (93.7%) vs. 178 of 194 (91.7%) (p=0.57) and the median decline in viral load (log10copies/mm3) was 2.7 in the IRIS vs. 1.1 in the non-IRIS groups (p<0.0001), respectively. An unfavourable response to TB therapy was detected in 17 of 82 (20.7%) and 28 of 210 (13.3%) in the IRIS and non-IRIS groups, respectively (p=0.14). CONCLUSIONS TB-IRIS frequently occurred in people with advanced HIV infection and in those who presented with extra-pulmonary TB lesions, without influencing subsequent TB treatment outcomes.
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Affiliation(s)
- Gopalan Narendran
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Keerthana Jyotheeswaran
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Thirumaran Senguttuvan
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Caian L Vinhaes
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil; Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil; Curso de Medicina, Faculdade de Tecnologia e Ciências (UniFTC), Salvador, Brazil
| | - Ramesh K Santhanakrishnan
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Tamizhselvan Manoharan
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Anbhalagan Selvaraj
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | | | - Pradeep A Menon
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Kannabiran P Bhavani
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Devarajulu Reddy
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Ravichandran Narayanan
- Government Hospital of Thoracic Medicine, Tambaram Sanatorium, Chennai, Tamil Nadu, India
| | - Balaji Subramanyam
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Sekhar Sathyavelu
- Rajiv Gandhi Government General Hospital, Park Town, Chennai, Tamil Nadu, India
| | - Raja Krishnaraja
- Government Hospital of Thoracic Medicine, Tambaram Sanatorium, Chennai, Tamil Nadu, India
| | - Pownraj Kalirajan
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Dhanalakshmi Angamuthu
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Stella Mary Susaimuthu
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | | | - Srikanth P Tripathy
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | | | - Bruno B Andrade
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil; Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil; Curso de Medicina, Faculdade de Tecnologia e Ciências (UniFTC), Salvador, Brazil; Universidade Salvador (UNIFACS), Laureate Universities, Salvador, Brazil; Escola Bahiana de Medicina e Saúde Pública (EBMSP), Salvador, Brazil; Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
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22
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Wijting IE, Wit FW, Rokx C, Leyten EM, Lowe SH, Brinkman K, Bierman WF, van Kasteren ME, Postma AM, Bloemen VC, Bouchtoubi G, Hoepelman AI, van der Ende ME, Reiss P, Rijnders BJ. Immune reconstitution inflammatory syndrome in HIV infected late presenters starting integrase inhibitor containing antiretroviral therapy. EClinicalMedicine 2019; 17:100210. [PMID: 31891143 PMCID: PMC6933261 DOI: 10.1016/j.eclinm.2019.11.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 10/01/2019] [Accepted: 11/07/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Integrase inhibitors (INI) induce a rapid decline of HIV-RNA in plasma and CD4+ T-cell recovery in blood. Both characteristics are also associated with immune reconstitution inflammatory syndrome (IRIS). Whether the use of INI-containing combination antiretroviral therapy (cART) increases the risk of IRIS is being questioned. METHODS Study within the Dutch ATHENA HIV observational cohort. HIV-1 infected late presenters initiating cART after March 2009 were included if they had <200 CD4+ T-cells per μL and were diagnosed with an opportunistic infection. IRIS was defined either according to the criteria by French et al. (IRISFRENCH) or by a clinical IRIS diagnosis of the physician (IRISCLINICAL). The primary outcomes were the association between INI and the occurrence of IRISFRENCH and IRISFRENCH+CLINICAL in multivariable logistic regression. FINDINGS 672 patients with a median CD4+ T-cell count of 35 cells per μL were included. Treatment with INI was independently associated with IRISFRENCH as well as IRISFRENCH+CLINICAL (OR 2·43, 95%CI:1·45-4·07, and OR 2·17, 95%CI:1·45-3·25). When investigating INI separately, raltegravir (RAL) remained significantly associated with IRISFRENCH (OR 4·04 (95%CI:1·99-8·19) as well as IRISFRENCH+CLINICAL (OR 3·07, 95%CI:1·66-5·69), while dolutegravir (DTG) became associated with IRISFRENCH+CLINICAL after it replaced RAL as preferred INI in the cohort after 2015 (OR 4·08, 95%CI:0·99-16·82, p=0·052). Too few patients used elvitegravir to draw meaningful conclusions. Steroid initiation for IRIS was more likely in those who initiated INI versus in those who did not, but no increased hospital (re)admission or mortality rates were observed. INTERPRETATION In HIV late presenters from a resource rich setting, INI based treatment initiation increased the risk of IRIS. This was observed for RAL and DTG when being initiated as preferential INI in the presence of specific AIDS-conditions, indicative of channeling bias. Although we controlled for all relevant measured confounders, we cannot exclude that the observed association is partially explained by residual confounding. INI use was not associated with mortality nor hospitalization. Therefore, our observation is no reason to avoid INI in late presenters. FUNDING The ATHENA database is maintained by Stichting HIV Monitoring and supported by a grant from the Dutch Ministry of Health, Welfare and Sport through the Centre for Infectious Disease Control of the National Institute for Public Health and the Environment.
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Affiliation(s)
- Ingeborg E.A. Wijting
- Department of Internal Medicine and Infectious Diseases, Erasmus MC, University Medical Center Rotterdam, ‘s Gravendijkwal 230, 3015 CE, Rotterdam, the Netherlands
| | - Ferdinand W.N.M. Wit
- Stichting HIV Monitoring and Department of Global Health and Division of Infectious Diseases, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Casper Rokx
- Department of Internal Medicine and Infectious Diseases, Erasmus MC, University Medical Center Rotterdam, ‘s Gravendijkwal 230, 3015 CE, Rotterdam, the Netherlands
| | - Eliane M.S. Leyten
- Department of Internal Medicine and Infectious Diseases, Haaglanden Medical Center, Lijnbaan 32, 2512 VH Den Haag, the Netherlands
| | - Selwyn H. Lowe
- Department of Internal Medicine and Infectious Diseases, Maastricht University Medical Center, Debyelaan, 6229 HX Maastricht, the Netherlands
| | - Kees Brinkman
- Department of Internal Medicine and Infectious Diseases, OLVG, Oosterpark 9, 1091 AC Amsterdam, the Netherlands
| | - Wouter F.W. Bierman
- Department of Internal Medicine/Infectious Diseases, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, the Netherlands
| | - Marjo E.E. van Kasteren
- Department of Internal Medicine and Infectious Diseases, ETZ, Hilvarenbeekse Weg 60, 5022 GC Tilburg, the Netherlands
| | - Anneloes M. Postma
- Department of Internal Medicine and Infectious Diseases, Erasmus MC, University Medical Center Rotterdam, ‘s Gravendijkwal 230, 3015 CE, Rotterdam, the Netherlands
| | - Vera C.M. Bloemen
- Department of Internal Medicine and Infectious Diseases, Erasmus MC, University Medical Center Rotterdam, ‘s Gravendijkwal 230, 3015 CE, Rotterdam, the Netherlands
| | - Ghariba Bouchtoubi
- Department of Internal Medicine and Infectious Diseases, Erasmus MC, University Medical Center Rotterdam, ‘s Gravendijkwal 230, 3015 CE, Rotterdam, the Netherlands
| | - Andy I.M. Hoepelman
- Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, University of Utrecht, Heidelberglaan 100, 3548 CX Utrecht, the Netherlands
| | - Marchina E. van der Ende
- Department of Internal Medicine and Infectious Diseases, Erasmus MC, University Medical Center Rotterdam, ‘s Gravendijkwal 230, 3015 CE, Rotterdam, the Netherlands
| | - Peter Reiss
- Stichting HIV Monitoring and Department of Global Health and Division of Infectious Diseases, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Bart J.A. Rijnders
- Department of Internal Medicine and Infectious Diseases, Erasmus MC, University Medical Center Rotterdam, ‘s Gravendijkwal 230, 3015 CE, Rotterdam, the Netherlands
- Corresponding author.
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Jung HJ, Ahn JY, Jang DH, Lee JI, Bae JY, Park MY. Skin Disease in Korean Human Immunodeficiency Virus Patient. Ann Dermatol 2019; 31:640-644. [PMID: 33911663 PMCID: PMC7992604 DOI: 10.5021/ad.2019.31.6.640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 09/07/2019] [Accepted: 09/17/2019] [Indexed: 11/16/2022] Open
Abstract
Background In Korea, new human immunodeficiency virus (HIV) patients continue to be diagnosed. Due to the development of highly active anti-retroviral therapy (HAART) and lengthening of survival period of infected person, the aspect of skin diseases of HIV-infected patients is also changing. Objective To determine skin diseases of HIV-infected patients according to immune status and the relationship between folliculitis and HAART drug. Methods Subjects were HIV-infected patients who were treated in the department of dermatology from September 1, 2008 to August 31, 2018. Medical records of 376 subjects were retrospectively analyzed. Results Of 376 patients were studied, tinea infection, folliculitis, and seborrheic dermatitis were the most common regardless of their CD4 T cell counts or treatment group (initial treatment or retreatment). Seborrheic dermatitis, irritant contact dermatitis, and pruritic papular eruption were significantly more common in patients with CD4+T cells less than 200×106 cells/L while warts were significantly more frequent in patients with CD4+T cells greater than 200×106 cells/L. Most HAART agents were found to be helpful in reducing the incidence of folliculitis. Conclusion There were many skin diseases in HIV patients, different from previous studies. In our study, the top three diagnoses were tinea infection, folliculitis, and seborrheic dermatitis. HAART medication was helpful in reducing folliculitis. These changes will require different treatments for skin diseases in HIV patients.
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Affiliation(s)
- Hye Jung Jung
- Department of Dermatology, National Medical Center, Seoul, Korea
| | - Ji Young Ahn
- Department of Dermatology, National Medical Center, Seoul, Korea
| | - Dong Hyek Jang
- Department of Dermatology, National Medical Center, Seoul, Korea
| | - Jae In Lee
- Department of Dermatology, National Medical Center, Seoul, Korea
| | - Joo Yoon Bae
- Department of Dermatology, National Medical Center, Seoul, Korea
| | - Mi Youn Park
- Department of Dermatology, National Medical Center, Seoul, Korea
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Tovar Salazar A, McKhann A, Chen H, Bosch RJ, Weinberg A. Immune Correlates of Herpes Zoster in People Living with HIV on Effective Antiretroviral Therapy. AIDS Res Hum Retroviruses 2019; 35:890-895. [PMID: 31179712 DOI: 10.1089/aid.2019.0053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Herpes zoster (HZ) has high morbidity in people living with HIV (PLHIV). We investigated immunological factors that correlated with the development of HZ in PLHIV with controlled HIV replication on antiretroviral therapy (ART). PLHIV who developed HZ on ART (cases), with undetectable plasma HIV RNA, and CD4 counts ≥200 cells/μL were matched 1:1 to controls by CD4 count, age, gender, race, and duration of ART. Varicella-zoster virus (VZV)-specific T cells and circulating regulatory T cells (Treg) were measured by flow cytometry before and after HZ. Differences between cases and controls were assessed by paired t-tests and longitudinal changes by Wilcoxon signed rank test. HZ cases (N = 31) had higher CD4+FOXP3+CD25+% Treg before HZ compared with 31 controls. After VZV ex vivo restimulation, cases had lower T cell responses, including CD8+perforin+% cytotoxic T lymphocytes (CTLs), CD4+IL10+%, and CD4+TGFβ+% compared with controls. Overall, Treg negatively correlated with VZV-specific Th1 responses. Moreover, Treg decreased over time on ART in HZ cases, VZV-CTLs were stable and did not increase even after HZ. Increased circulating Treg and decreased VZV-specific T cell immune responses were associated with the risk of HZ in PLHIV. The kinetics of Treg over time, but not of VZV-CTLs, paralleled the natural history of HZ, whose incidence decreases over time on effective ART.
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Affiliation(s)
- Adriana Tovar Salazar
- Department of Pediatrics, Anschutz Medical Center University of Colorado Denver, Aurora, Colorado
| | - Ashley McKhann
- Center for Biostatistics in AIDS Research, Harvard TH Chan School of Public Health, Boston, Massachusetts
| | - Huichao Chen
- Center for Biostatistics in AIDS Research, Harvard TH Chan School of Public Health, Boston, Massachusetts
| | - Ronald J. Bosch
- Center for Biostatistics in AIDS Research, Harvard TH Chan School of Public Health, Boston, Massachusetts
| | - Adriana Weinberg
- Department of Pediatrics, Anschutz Medical Center University of Colorado Denver, Aurora, Colorado
- Department of Medicine, Anschutz Medical Center University of Colorado Denver, Aurora, Colorado
- Department of Pathology, Anschutz Medical Center University of Colorado Denver, Aurora, Colorado
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The tuberculosis-associated immune reconstitution inflammatory syndrome: recent advances in clinical and pathogenesis research. Curr Opin HIV AIDS 2019; 13:512-521. [PMID: 30124473 PMCID: PMC6181275 DOI: 10.1097/coh.0000000000000502] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Purpose of review Antiretroviral therapy (ART) is an essential, life-saving intervention for HIV infection. However, ART initiation is frequently complicated by the tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) in TB endemic settings. Here, we summarize the current understanding highlighting the recent evidence. Recent findings The incidence of paradoxical TB-IRIS is estimated at 18% (95% CI 16–21%), higher than previously reported and may be over 50% in high-risk groups. Early ART initiation in TB patients increases TB-IRIS risk by greater than two-fold, but is critical in TB patients with CD4 counts less than 50 cells/μl because it improves survival. There remains no validated diagnostic test for TB-IRIS, and biomarkers recently proposed are not routinely used. Prednisone initiated alongside ART in selected patients with CD4 less than 100 cells/μl reduced the risk of paradoxical TB-IRIS by 30% in a recent randomized-controlled trial (RCT) and was not associated with significant adverse effects. Effective also for treating paradoxical TB-IRIS, corticosteroids remain the only therapeutic intervention for TB-IRIS supported by RCT trial data. TB-IRIS pathogenesis studies implicate high antigen burden, innate immune cell cytotoxicity, inflammasome activation and dysregulated matrix metalloproteinases in the development of the condition. Summary Specific biomarkers would aid in identifying high-risk patients for interventions and a diagnostic test is needed. Clinicians should consider prednisone for TB-IRIS prevention in selected patients. Future research should focus on improving diagnosis and investigating novel therapeutic interventions, especially for patients in whom corticosteroid therapy is contraindicated.
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Cotton MF, Rabie H, Nemes E, Mujuru H, Bobat R, Njau B, Violari A, Mave V, Mitchell C, Oleske J, Zimmer B, Varghese G, Pahwa S. A prospective study of the immune reconstitution inflammatory syndrome (IRIS) in HIV-infected children from high prevalence countries. PLoS One 2019; 14:e0211155. [PMID: 31260455 PMCID: PMC6602181 DOI: 10.1371/journal.pone.0211155] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 05/31/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The immune reconstitution inflammatory syndrome (IRIS) in HIV-infected infants and young children is relatively understudied in regions endemic for HIV and TB. We aimed to describe incidence, clinical features and risk factors of pediatric IRIS in Sub-Saharan Africa and India. METHODS AND FINDINGS We conducted an observational multi-centred prospective clinical study from December 2010 to September 2013 in children <72 months of age recruited from public antiretroviral programs. The main diagnostic criterion for IRIS was a new or worsening inflammatory event after initiating antiretroviral therapy (ART). Among 198 participants, median age 1.15 (0.48; 2.21) years, 38 children (18.8%) developed 45 episodes of IRIS. Five participants (13.2%) had two IRIS events and one (2.6%) had 3 events. Main causes of IRIS were BCG (n = 21; 46.7%), tuberculosis (n = 10; 22.2%) and dermatological, (n = 8, 17.8%). Four TB IRIS cases had severe morbidity including 1 fatality. Cytomegalovirus colitis and cryptococcal meningitis IRIS were also severe. BCG IRIS resolved without pharmacological intervention. On multivariate logistic regression, the most important baseline associations with IRIS were high HIV viral load (likelihood ratio [LR] 10.629; p = 0.0011), recruitment at 1 site (Stellenbosch University) (LR 4.01; p = 0.0452) and CD4 depletion (LR 3.4; p = 0.0654). Significantly more non-IRIS infectious and inflammatory events between days 4 and 17 of ART initiation were noted in cases versus controls (35% versus 15.2%: p = 0.0007). CONCLUSIONS IRIS occurs commonly in HIV-infected children initiating ART and occasionally has severe morbidity. The incidence may be underestimated. Predictive, diagnostic and prognostic biomarkers are needed.
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Affiliation(s)
- Mark F. Cotton
- Department of Pediatrics & Child Health, Stellenbosch University, Tygerberg, South Africa
| | - Helena Rabie
- Department of Pediatrics & Child Health, Stellenbosch University, Tygerberg, South Africa
| | - Elisa Nemes
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease & Molecular Medicine and Division of Immunology, Pathology, University of Cape Town, Cape Town, South Africa
| | - Hilda Mujuru
- Department of Pediatrics, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Raziya Bobat
- Department of Pediatrics & Child Health, University of KwaZulu-Natal, Durban, South Africa
| | - Boniface Njau
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Avy Violari
- Department of Pediatrics & Child Health, Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Charles Mitchell
- Department of Pediatric Immunology, University of Miami, Miami, FL, United States of America
| | - James Oleske
- Department of Pediatrics & Child Health, Rutgers New Jersey Medical School, Newark, NJ, United States of America
| | - Bonnie Zimmer
- Frontier Science & Technology Research Foundation, Amherst, NY, United States of America
| | - George Varghese
- Department of Pediatrics & Child Health, University of Miami Miller School of Medicine, Miami, FL, United States of America
| | - Savita Pahwa
- Department of Pediatrics & Child Health, University of Miami Miller School of Medicine, Miami, FL, United States of America
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Demitto FO, Schmaltz CAS, Sant'Anna FM, Arriaga MB, Andrade BB, Rolla VC. Predictors of early mortality and effectiveness of antiretroviral therapy in TB-HIV patients from Brazil. PLoS One 2019; 14:e0217014. [PMID: 31170171 PMCID: PMC6553696 DOI: 10.1371/journal.pone.0217014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 05/02/2019] [Indexed: 01/03/2023] Open
Abstract
Background The implementation of antiretroviral (ARV) therapy caused a significant decrease in HIV-associated mortality worldwide. Nevertheless, mortality is still high among people living with HIV/AIDS and tuberculosis (TB). ARV-naïve HIV patients coinfected with tuberculosis (TB) have more options to treat both diseases concomitantly. Nevertheless, some TB-HIV patients undertaking ARVs (ARV-experienced) are already failing the first line efavirenz-based regimen and seem to display different response to second line ARV therapy and exhibit other predictors of mortality. Methods We performed a retrospective cohort study including 273 patients diagnosed with TB-HIV and treated at a referral center in Rio de Janeiro, Brazil, between 2008 and 2016. Multivariate analysis and Cox regression models were used to evaluate the effectiveness of ARV therapy regimens (viral load [VL] <80 copies from the 4th to 10th months after TB therapy introduction) and to identify predictors of early mortality (100 days after TB therapy initiation) considering ARV-naïve and ARV-experienced patients adjusting for sociodemographic, clinical and therapeutic covariates. Findings Survival analysis included 273 patients, out of whom 154 (56.4%) were ARV-naïve and 119 (43.6%) were ARV-experienced. Seven deaths occurred within 6 months of anti-TB treatment, 4 in ARV-naïve and 3 in ARV-experienced patients. Multivariate analysis revealed that in ARV-naïve patients, the chance of death was substantially higher in patients who developed immune reconstitution inflammatory syndrome during the study follow up (HR = 40.6, p<0.01). For ARV-experienced patients, similar analyses failed to identify factors significantly associated with mortality. Variables independently associated with treatment failure for the ARV-naïve group were previous TB (adjusted OR [aOR] = 6.1 p = 0.03) and alcohol abuse (aOR = 3.7 p = 0.01). For ARV-experienced patients, a ritonavir boosted. Protease Inhibitor-based regimen resulted in a 2.6 times higher risk of treatment failure compared to the use of efavirenz based ARV regimens (p = 0.03) and High baseline HIV VL (p = 0.03) were predictors of treatment failure. Conclusions Risk factors for mortality and ARV failure were different for ARV-naïve and ARV-experienced patients. The latter patient group should be targeted for trials with less toxic and rifampicin-compatible drugs to improve TB-HIV treatment outcomes and prevent death.
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Affiliation(s)
- Fernanda O Demitto
- Programa de Pós-Graduação em Pesquisa Clínica em Doenças Infecciosas, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Carolina A S Schmaltz
- Laboratório de Pesquisa Clínica em Micobacterioses (LAPCLIN-TB), Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Flávia M Sant'Anna
- Laboratório de Pesquisa Clínica em Micobacterioses (LAPCLIN-TB), Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - María B Arriaga
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil.,Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
| | - Bruno B Andrade
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil.,Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil.,Escola Bahiana de Medicina e Saúde Pública (EBMSP), Salvador, Brazil.,Universidade Salvador (UNIFACS), Laureate Universities, Salvador, Brazil.,Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, Republic of South Africa.,Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - Valeria C Rolla
- Programa de Pós-Graduação em Pesquisa Clínica em Doenças Infecciosas, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil.,Laboratório de Pesquisa Clínica em Micobacterioses (LAPCLIN-TB), Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
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Ahmed I, Lemma S. Mortality among pediatric patients on HIV treatment in sub-Saharan African countries: a systematic review and meta-analysis. BMC Public Health 2019; 19:149. [PMID: 30717720 PMCID: PMC6360742 DOI: 10.1186/s12889-019-6482-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 01/25/2019] [Indexed: 12/29/2022] Open
Abstract
Background Despite substantial improvements in accessibility of Anti-Retroviral Treatment (ART), death of children on ART remains a prevailing challenge in sub-Saharan African (SSA) countries. However, the pooled magnitude of mortality at different ART follow-up periods remains unknown for the region. We estimated the pooled proportion of all-cause mortality for pediatric patients receiving first-line ART at 3, 6, 12, and 24 months follow-up period in SSA. Methods We searched for relevant articles published between January 2014 and June 2018 on PubMed, Hinari and Google scholar databases. We searched for additional articles from reference lists and 2014–2018 abstracts archived by the Conference on Retroviruses and Opportunistic Infections (CROI) and the International AIDS Society Conference on HIV Science (IAS). Results We reviewed 29 articles reporting mortality among pediatric ART patients at different follow-up periods in countries from 2001 to 2016. Among the 51,619 pediatric ART patients in these cohorts, studies reported 4061 (7.9%) all-cause cumulative death. The cumulative pooled proportion of mortality at 3, 6, 12 and 24 months of ART were 3% (95% CI: 3.0–4.0), 5% (95% CI: 4.0–6.0), 6% (95% CI: 5.0–7.0) and 7% (95% CI: 6.0–8.0), respectively. Conclusions In SSA, significant proportion of mortality among children occurs in the first 3–6 months of ART initiation. Western Africa has a little higher estimate of mortality among pediatric ART patients at 6 and 12 months of follow-up. Strategies to prevent early mortality including thorough screening and management of opportunistic infections before ART initiation are needed. Electronic supplementary material The online version of this article (10.1186/s12889-019-6482-1) contains supplementary material, which is available to authorized users.
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Wang Y, Wu Q, Zhang W, Zhang N. Tuberculosis and HIV Coinfection–the Challenge in the Prevention, Detection and Treatment of Tuberculosis. Curr Bioinform 2019. [DOI: 10.2174/1574893613666180621153734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background:
Tuberculosis (TB) is still a major public health concern world-wide. The
increasing global burden of TB is linked to HIV infection. HIV-TB coinfection has also
conditioned clinical aspects of the TB. Since the HIV is beginning in the 1980s, the HIV infection
poses a significant challenge in global TB control.
Objective:
In this review we focused on the challenges of epidemiological and clinical feature of
tuberculosis presented by the HIV coinfection.
Method:
The article consists of a summary of the most important effects presented by the HIV
coinfection on epidemiological and clinical feature of tuberculosis. The article analyzes and
summary the causes for these challenges.
Results:
The major challenges to strategy of TB control and clinical feature of TB-HIV coinfection
are presented in this paper.
Conclusion:
HIV/TB co-infection is synergic, interactive and reciprocal with significant impact.
The infection of HIV and Mtb affect each other and the breakdown the immune function in
TB/HIV coinfected individual. HIV infection has changed the strategy of TB control, however
HIV increases global burden of TB, the reduction in the TB incidence rate is far from sufficient.
Atypically clinical manifestations in TB/HIV co-infected patients and increased MDR-TB and
XDR-TB contribute to the challenges in the diagnosis and treatment. Increased complexity of
managing patients requires expertise in the clinical m knowledge. The focused efforts to control
HIV-related TB are of great urgency. These findings will provide insight into the prevention,
detection and treatment of tuberculosis and will guide advances towards tuberculosis control.
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Affiliation(s)
- Yiyi Wang
- TCM Key Research Laboratory for Infectious Disease Prevention for State Administration of Traditional Chinese Medicine, China
| | - Qi Wu
- TCM Key Research Laboratory for Infectious Disease Prevention for State Administration of Traditional Chinese Medicine, China
| | - Wei Zhang
- Clinical and Research Center of Infectious Diseases Beijing Ditan Hospital, Capital Medical University, 100015, Peiking, China
| | - Ning Zhang
- Department of Biomedical Engineering, Tianjin Key Lab of Biomedical Engineering Measurement, Tianjin University, Tianjin, China
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Aranda-Audelo M, Rivera-Martínez NE, Corzo-León DE. Characteristics of Invasive Fungal Infections among HIV Individuals from an Indigenous Origin in Mexico. J Fungi (Basel) 2018; 4:E109. [PMID: 30205586 PMCID: PMC6162685 DOI: 10.3390/jof4030109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 09/06/2018] [Accepted: 09/07/2018] [Indexed: 11/29/2022] Open
Abstract
In individuals with HIV/AIDS, 47% of the deaths are attributed to invasive fungal infections (IFIs), despite antiretroviral (ARV) therapy. This is a retrospective study carried out in the Hospital Regional de Alta Especialidad Oaxaca (HRAEO), southwest Mexico, where IFIs that occurred during 2016⁻2017 are described. A total of 55 individuals were included. Histoplasmosis (36%) and possible-IFIs in neutropenic fever (20%) were the most frequent cases, followed by cryptococcosis (14%). The HIV/AIDS subpopulation corresponded with 26 cases (47%), all from an indigenous origin. The incidence of IFIs among them was 24% (95% CI = 15⁻33%). The CD4+ T cells median was 35 cells/mL (IQR 12⁻58). Four cases (15%) of unmasking IRIS were identified, three of histoplasmosis and one coccidioidomycosis. Co-infections were found in 52% (12/23), and tuberculosis in 50% (6/12) was the most frequent. The mortality rate was 48%. The general characteristics of the HIV individuals who died were atypical pneumonia (70% vs. 9%, p = 0.01), acute kidney injury, (70% vs. 9%, p = 0.008) and ICU stay (80% vs. 9%, p = 0.002). In conclusion, IFIs are diagnosed in one out of four individuals with HIV/AIDS along with other complicated infectious conditions, leading to major complications and a high mortality rate.
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Affiliation(s)
- Mercedes Aranda-Audelo
- Infectious Diseases Department, Hospital Regional de Alta Especialidad de Oaxaca, Avenida Aldama S/N, Centro, San Bartolo Coyotepec 71256, Oax, Mexico.
| | - Norma E Rivera-Martínez
- Infectious Diseases Department, Hospital Regional de Alta Especialidad de Oaxaca, Avenida Aldama S/N, Centro, San Bartolo Coyotepec 71256, Oax, Mexico.
| | - Dora E Corzo-León
- Medical Research Centre for Medical Mycology, Wellcome Trust Strategic Award, Institute of Medical Science, University of Aberdeen, King's College, Aberdeen AB24 3FX, UK.
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O'Connor DE, Frederix K, Saito S, Maama LB, Hirsch-Moverman Y, Pitt B, Hayes-Larson E, Lebelo L, Shale M, Howard AA. Pulmonary tuberculosis diagnostic practices among people living with the human immunodeficiency virus in Lesotho. Int J Tuberc Lung Dis 2018; 21:1133-1138. [PMID: 28911357 DOI: 10.5588/ijtld.17.0297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Twelve health facilities in Berea District, Lesotho, that participated in the Start TB Patients on ART and Retain on Treatment (START) Study, a mixed-methods cluster-randomized trial evaluating a combination intervention package to improve early initiation of antiretroviral therapy (ART) and anti-tuberculosis treatment success among patients with tuberculosis (TB) and human immunodeficiency virus (HIV). OBJECTIVE To assess TB and HIV diagnostic practices among TB-HIV patients. DESIGN A standardized survey assessed services at each facility at baseline. Routine clinical data were abstracted for all newly registered adult TB-HIV patients during the study period. Descriptive statistics were used to assess TB diagnostic practices, timing of the HIV diagnosis, and ART status at TB treatment initiation. RESULTS Between April 2013 and March 2015, 1233 TB-HIV patients were enrolled. Among 1215 patients with available data, 87.2% had pulmonary TB, of which 34.8% were bacteriologically confirmed, 40.9% tested negative and 24.3% were not tested. Among 1138 patients with available data, 53.3% had an existing HIV diagnosis, of whom 39.3% were ART-naïve. CONCLUSIONS The majority of pulmonary TB patients were clinically diagnosed, and many were unaware of their HIV status or were ART-naïve despite known status. The Test and Treat Strategy holds promise to prevent TB and reduce TB-related mortality among people living with HIV; however, enhanced TB diagnostic capacity and improved HIV case detection are urgently needed.
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Affiliation(s)
- D E O'Connor
- ICAP at Columbia University, Mailman School of Public Health, New York, New York, College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - K Frederix
- ICAP at Columbia University, Maseru, Lesotho
| | - S Saito
- ICAP at Columbia University, Mailman School of Public Health, New York, New York, Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - L B Maama
- National Tuberculosis Program, Lesotho Ministry of Health, Maseru, Lesotho
| | - Y Hirsch-Moverman
- ICAP at Columbia University, Mailman School of Public Health, New York, New York, Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - B Pitt
- ICAP at Columbia University, Maseru, Lesotho
| | - E Hayes-Larson
- ICAP at Columbia University, Mailman School of Public Health, New York, New York, Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - L Lebelo
- ICAP at Columbia University, Maseru, Lesotho
| | - M Shale
- ICAP at Columbia University, Maseru, Lesotho
| | - A A Howard
- ICAP at Columbia University, Mailman School of Public Health, New York, New York, Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
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Zeldow B, Kim S, McSherry G, Cotton MF, Jean-Philippe P, Violari A, Bobat R, Nachman S, Mofenson LM, Madhi SA, Mitchell C. Use of antiretrovirals in HIV-infected children in a tuberculosis prevention trial: IMPAACT P1041. Int J Tuberc Lung Dis 2018; 21:38-45. [PMID: 28157463 DOI: 10.5588/ijtld.16.0149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
SETTING International Maternal Pediatric Adolescent AIDS Clinical Trials (IMPAACT) P1041, a tuberculosis (TB) prevention trial conducted among children enrolled from 2004 to 2008 during South Africa's roll-out of combination antiretroviral therapy (ART). OBJECTIVE To estimate TB incidence and mortality and the effect of ART. DESIGN Children were pre-screened to exclude TB disease and exposure, actively screened 3-monthly for TB exposure and symptoms, and provided post-exposure isoniazid prophylaxis therapy (IPT). TB diagnoses were definite, probable, or possible, and mortality all-cause. Testing was at the 5% significance level. RESULTS In 539 children (aged 3-4 months) followed up for a median of 74 weeks (interquartile range [IQR] 48-116), incidence/100 person-years (py) was 10.67 (95%CI 8.47-13.26) for any TB and 2.89 (95%CI 1.85-4.31) for definite/probable TB. Any TB incidence was respectively 9.39, 13.59, and 9.83/100 py before, <180 days after, and 180 days after ART initiation. Adjusted analysis showed a non-significant increase in any TB (HR 1.32, 95%CI 0.71-2.52, P = 0.38) and a significant reduction in mortality (HR 0.39, 95%CI 0.17-0.82, P = 0.017) following ART initiation. CONCLUSIONS ART reduced mortality but not TB incidence in human immunodeficiency virus (HIV) infected children in IMPAACT P1041, possibly attributable to active screening for TB exposure and symptoms with post-exposure IPT. Research into this as a strategy for TB prevention in high HIV-TB burden settings may be warranted.
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Affiliation(s)
- B Zeldow
- Center for Biostatistics in AIDS Research, Harvard School of Public Health, Boston, Massachusetts, USA
| | - S Kim
- Center for Biostatistics in AIDS Research, Harvard School of Public Health, Boston, Massachusetts, USA; Department of Biostatistics, Rutgers School of Public Health, Newark, New Jersey, USA
| | - G McSherry
- Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - M F Cotton
- Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - P Jean-Philippe
- Henry Jackson Foundation-National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - A Violari
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - R Bobat
- Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa
| | - S Nachman
- State University of New York at Stony Brook, Stony Brook, New York, USA
| | - L M Mofenson
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Rockville, Maryland, USA; Elizabeth Glaser Pediatric AIDS Foundation, Washington DC, USA
| | - S A Madhi
- Respiratory and Meningeal Pathogens Research Unit, Medical Research Council, University of the Witwatersrand, Johannesburg, South Africa
| | - C Mitchell
- University of Miami Miller School of Medicine, Miami, Florida, USA
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Benjamin LA, Allain TJ, Mzinganjira H, Connor MD, Smith C, Lucas S, Joekes E, Kampondeni S, Chetcuti K, Turnbull I, Hopkins M, Kamiza S, Corbett EL, Heyderman RS, Solomon T. The Role of Human Immunodeficiency Virus-Associated Vasculopathy in the Etiology of Stroke. J Infect Dis 2017; 216:545-553. [PMID: 28931222 PMCID: PMC5853476 DOI: 10.1093/infdis/jix340] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 07/18/2017] [Indexed: 01/25/2023] Open
Abstract
Background Human immunodeficiency virus (HIV) infection is a recognized risk factor for stroke among young populations, but the exact mechanisms are poorly understood. We studied the clinical, radiologic, and histologic features of HIV-related ischemic stroke to gain insight into the disease mechanisms. Methods We conducted a prospective, in-depth analysis of adult ischemic stroke patients presenting to Queen Elizabeth Central Hospital, Blantyre, Malawi, in 2011. Results We recruited 64 HIV-infected and 107 HIV-uninfected patients. Those with HIV were significantly younger (P < .001) and less likely to have established vascular risk factors. Patients with HIV were more likely to have large artery disease (21% vs 10%; P < .001). The commonest etiology was HIV-associated vasculopathy (24 [38%]), followed by opportunistic infections (16 [25%]). Sixteen of 64 (25%) had a stroke soon after starting antiretroviral therapy (ART), suggesting an immune reconstitution-like syndrome. In this group, CD4+ T-lymphocyte count was low, despite a significantly lower HIV viral load in those recently started on treatment (P < .001). Conclusions HIV-associated vasculopathy and opportunistic infections are common causes of HIV-related ischemic stroke. Furthermore, subtypes of HIV-associated vasculopathy may manifest as a result of an immune reconstitution-like syndrome after starting ART. A better understanding of this mechanism may point toward new treatments.
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Affiliation(s)
- Laura A Benjamin
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre.,Brain Infections Group, Institute of Infection and Global Health, University of Liverpool, United Kingdom.,Department of Medicine, College of Medicine, University of Malawi, Blantyre.,Walton Centre NHS Foundation Trust, Liverpool
| | - Theresa J Allain
- Department of Medicine, College of Medicine, University of Malawi, Blantyre
| | - Henry Mzinganjira
- Department of Medicine, College of Medicine, University of Malawi, Blantyre
| | - Myles D Connor
- NHS Borders, Melrose.,Division of Clinical Neurosciences, University of Edinburgh, United Kingdom.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Colin Smith
- Centre for Clinical Brain Sciences, University of Edinburgh
| | - Sebastian Lucas
- Department of Histopathology, North Wing, St Thomas' Hospital, London
| | | | - Sam Kampondeni
- Department of Medicine, College of Medicine, University of Malawi, Blantyre
| | - Karen Chetcuti
- Department of Radiology, Alder Hey Children's NHS Foundation Trust, Liverpool
| | | | - Mark Hopkins
- Royal Liverpool University Hospital, United Kingdom
| | - Steve Kamiza
- Department of Pathology, College of Medicine, University of Malawi, Blantyre
| | - Elizabeth L Corbett
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre.,Department of Clinical Research, London School of Hygiene and Tropical Medicine
| | - Robert S Heyderman
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre.,Division of Infection and Immunity, University College London
| | - Tom Solomon
- Brain Infections Group, Institute of Infection and Global Health, University of Liverpool, United Kingdom.,Walton Centre NHS Foundation Trust, Liverpool.,Health Protection Research Unit in Emerging and Zoonotic Infections, National Institute for Health Research, Liverpool, United Kingdom
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Narendran G, Swaminathan S. TB-HIV co-infection: a catastrophic comradeship. Oral Dis 2017; 22 Suppl 1:46-52. [PMID: 27109272 DOI: 10.1111/odi.12389] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 08/07/2015] [Accepted: 11/12/2015] [Indexed: 11/30/2022]
Abstract
The symbiotic association of tuberculosis (TB) and HIV poses a challenge to human survival. HIV complicates every aspect of TB including presentation, diagnosis and treatment. HIV-TB patients encounter unique problems like drug-drug interactions, cumulative toxicity, immune reconstitution inflammatory syndrome (IRIS), lower plasma drug levels and emergence of drug resistance during treatment despite adherence. TB may also be overdiagnosed in HIV due to a number of diseases that closely resemble TB. Notable among them are non-tuberculous mycobacteria, Pneumocystis Jirovecii and Nocardia. Even though diagnostic procedures have improved over the years, patients in developing countries usually seek health care at later stage of the disease. Research data ascertains the duration of therapy for TB to be 6 months with rifampicin and isoniazid, reinforced with ethambutol and pyrazinamide in the first 2 months. The schedule of therapy is still debatable with daily regimens being preferred in the context of HIV. Many reasons exist for persistence of Mycobacterium Tuberculosis (M.TB) in sputum, or delayed-clearance of TB from sputum smears in HIV, apart from emergence of drug resistance and non-compliance. Acquired rifampicin resistance (ARR) is a unique phenomenon complicating HIV-associated TB when an intermittent regimen of antituberculosis therapy (ATT) is used without timely initiation of highly active antiretroviral therapy (HAART), especially in patients harbouring isoniazid-resistant strains Immune restoration is often incomplete ('swiss cheese' pattern) even with effective HAART if not started early. Immune reconstitution inflammatory syndrome (IRIS) is the paradoxical worsening of the patient's condition often with radiological deterioration, due to an enhanced immune response with HAART. IRIS occurs despite an effective virological suppression and a favourable response to ATT. The incidence of IRIS in HIV has reached up to 54%, requiring utilization of experts and tertiary care which forms an obstacle to the decentralization of patients in the ART programme. Research in HIV-TB immunology and management needs further exploration in order to understand the diseases and offer appropriate treatment. The following paragraphs provide scientific evidences generated through research that could potentially guide management.
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Affiliation(s)
- G Narendran
- National Institute for Research in Tuberculosis, Chennai, India
| | - S Swaminathan
- National Institute for Research in Tuberculosis, Chennai, India
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35
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Pérez-Rueda M, Hernández-Cabrera M, Francés-Urmeneta A, Angel-Moreno A, Pisos-Álamo E, Jaén-Sánchez N, Carranza-Rodríguez C, Pérez-Arellano JL. Immune Reconstitution Inflammatory Syndrome in HIV-Infected Immigrants. Am J Trop Med Hyg 2017; 97:1072-1077. [PMID: 28820685 DOI: 10.4269/ajtmh.16-0773] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) includes a group of potentially serious inflammatory processes that may be present in HIV-infected patients after initiating highly active antiretroviral therapy (HAART). Paradoxical IRIS is a worsening of symptoms, after an overwhelming response to a previously diagnosed opportunistic infection (OI); unmasking IRIS reveals a previously occult OI. The main objective of the study was to describe the epidemiological, clinical, and outcome data of HIV-infected immigrants, stratified according to high- or low-income countries of origin, who developed IRIS and to compare them with native-born Spanish patients. This retrospective study reviewed all patients with HIV infection admitted to the Unit of Infectious Diseases and Tropical Medicine between 1998 and 2014. IRIS was identified in 25/138 (18%) immigrant patients and 24/473 (5%) native-born Spanish patients infected with HIV. Most cases, 19/25 (76%), were of unmasking IRIS. The time elapsed between initiation of HAART and development of IRIS was significantly longer in patients with unmasking versus paradoxical IRIS. OIs, in particular due to mycobacteria, were the most frequently involved processes. Twenty percent of patients died. The comparison of immigrant and native-born patients found significant differences for both IRIS type (higher incidence of paradoxical forms among immigrants) and for the absence of malignancies in native-born patients. No significant differences were found when the data of immigrants from low- and high-income countries were compared.
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Affiliation(s)
- María Pérez-Rueda
- Internal Medicine, Hospital San Roque Maspalomas (HSRM), Gran Canaria, Spain
| | - Michele Hernández-Cabrera
- Unit of Infectious Diseases and Tropical Medicine, Hospital Universitario Insular de Gran Canaria (HUIGC), Las Palmas, Spain.,Department of Medical and Surgical Sciences, University of Las Palmas, Las Palmas, Spain
| | - Adela Francés-Urmeneta
- Unit of Infectious Diseases and Tropical Medicine, Hospital Universitario Insular de Gran Canaria (HUIGC), Las Palmas, Spain
| | | | - Elena Pisos-Álamo
- Unit of Infectious Diseases and Tropical Medicine, Hospital Universitario Insular de Gran Canaria (HUIGC), Las Palmas, Spain.,Department of Medical and Surgical Sciences, University of Las Palmas, Las Palmas, Spain
| | - Nieves Jaén-Sánchez
- Unit of Infectious Diseases and Tropical Medicine, Hospital Universitario Insular de Gran Canaria (HUIGC), Las Palmas, Spain.,Department of Medical and Surgical Sciences, University of Las Palmas, Las Palmas, Spain
| | - Cristina Carranza-Rodríguez
- Unit of Infectious Diseases and Tropical Medicine, Hospital Universitario Insular de Gran Canaria (HUIGC), Las Palmas, Spain.,Department of Medical and Surgical Sciences, University of Las Palmas, Las Palmas, Spain
| | - Jose-Luis Pérez-Arellano
- Department of Medical and Surgical Sciences, University of Las Palmas, Las Palmas, Spain.,Unit of Infectious Diseases and Tropical Medicine, Hospital Universitario Insular de Gran Canaria (HUIGC), Las Palmas, Spain
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Nelson AM, Manabe YC, Lucas SB. Immune Reconstitution Inflammatory Syndrome (IRIS): What pathologists should know. Semin Diagn Pathol 2017; 34:340-351. [PMID: 28552210 DOI: 10.1053/j.semdp.2017.04.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Antiretroviral therapy has significantly improved the quality and length of life for those patients able to access effective and sustained treatment. The resulting restoration of the immune response is associated with a change in the clinical presentation of opportunistic infections, and the histologic reaction to pathogens. A complex combination of alterations in host response across the stages of HIV infection has been documented over the past 3 decades. The defects are seen in both acute and chronic phases of inflammation and involve innate and adaptive immunity. In advanced stages of HIV infection, the marked disruption of lymphoid tissue and loss of follicular dendritic cells limits the host's ability to process antigen and mount specific responses to pathogens. There are qualitative and quantitative defects in CD4 T cells due to HIV infection. The resulting indirect effects include loss of cytokine production, dysregulation of B-cell function, loss of cellular mediated immunity and "holes" in the immunologic repertoire that may not be restored with the use of antiretroviral therapy. Immune reconstitution allows the host to respond to and control infection, but a significant number of patients will have atypical inflammatory syndromes during the recovery period. We briefly discuss the impact of HIV infection on the immune system and give an overview of the spectrum of conditions attributed to the Immune Reconstitution Inflammatory syndrome (IRIS).
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Thambuchetty N, Mehta K, Arumugam K, Shekarappa UG, Idiculla J, Shet A. The Epidemiology of IRIS in Southern India: An Observational Cohort Study. J Int Assoc Provid AIDS Care 2017; 16:475-480. [PMID: 28399724 DOI: 10.1177/2325957417702485] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) is an uncommon but dynamic phenomenon seen among patients initiating antiretroviral therapy (ART). We aimed to describe incidence, risk factors, clinical spectrum, and outcomes among ART-naive patients experiencing IRIS in southern India. Among 599 eligible patients monitored prospectively between 2012 and 2014, there were 59.3% males, with mean age 36.6 ± 7.8 years. Immune reconstitution inflammatory syndrome incidence rate was 51.3 per 100 person-years (95% confidence interval: 44.5-59.2). One-third (31.4%) experienced at least 1 IRIS event, at a median of 27 days since ART initiation. Mucocutaneous infections and candidiasis were common IRIS events, followed by tuberculosis. Significant risk factors included age >40 years, body mass index <18.5 kg/m2, CD4 count <100 cells/mm3, viral load >10 000 copies/mL, hemoglobin <11 g/dL, and erythrocyte sedimentation rate >50 mm/h. Immune reconstitution inflammatory syndrome-related morality was 1.3% (8 of 599); 3 patients died of complicated diarrhea. These findings highlight the current spectrum of IRIS in South India and underscore the importance of heightened vigilance for anemia and treatment of diarrhea and candidiasis during ART initiation.
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Affiliation(s)
- Nisha Thambuchetty
- 1 Department of General Surgery, Father Muller Medical College Hospital, Mangalore, Karnataka, India
| | - Kayur Mehta
- 2 Division of Pediatric Infectious Diseases, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Karthika Arumugam
- 3 Division of Biostatistics, St John's Research Institute, Bangalore, Karnataka, India
| | - Umadevi G Shekarappa
- 4 Antiretroviral Treatment (ART) Centre, St John's Medical College Hospital, Bangalore, Karnataka, India
| | - Jyothi Idiculla
- 5 Department of Medicine, St John's Medical College, Bangalore, Karnataka, India
| | - Anita Shet
- 6 International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Gopalan N, Chandrasekaran P, Swaminathan S, Tripathy S. Current trends and intricacies in the management of HIV-associated pulmonary tuberculosis. AIDS Res Ther 2016; 13:34. [PMID: 27708678 PMCID: PMC5037900 DOI: 10.1186/s12981-016-0118-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 09/16/2016] [Indexed: 01/08/2023] Open
Abstract
Human immunodeficiency virus (HIV) epidemic has undoubtedly increased the incidence of tuberculosis (TB) globally, posing a formidable global health challenge affecting 1.2 million cases. Pulmonary TB assumes utmost significance in the programmatic perspective as it is readily transmissible as well as easily diagnosable. HIV complicates every aspect of pulmonary tuberculosis from diagnosis to treatment, demanding a different approach to effectively tackle both the diseases. In order to control these converging epidemics, it is important to diagnose early, initiate appropriate therapy for both infections, prevent transmission and administer preventive therapy. Liquid culture methods and nucleic acid amplification tests for TB confirmation have replaced conventional solid media, enabling quicker and simultaneous detection of mycobacterium and its drug sensitivity profile Unique problems posed by the syndemic include Acquired rifampicin resistance, drug-drug interactions, malabsorption of drugs and immune reconstitution inflammatory syndrome or paradoxical reaction that complicate dual and concomitant therapy. While the antiretroviral therapy armamentarium is constantly reinforced by discovery of newer and safer drugs every year, only a few drugs for anti tuberculosis treatment have successfully emerged. These include bedaquiline, delamanid and pretomanid which have entered phase III B trials and are also available through conditional access national programmes. The current guidelines by WHO to start Antiretroviral therapy irrespective of CD4+ cell count based on benefits cited by recent trials could go a long way in preventing various complications caused by the deadly duo. This review provides a consolidated gist of the advancements, concepts and updates that have emerged in the management of HIV-associated pulmonary TB for maximizing efficacy, offering latest solutions for tackling drug-drug interactions and remedial measures for immune reconstitution inflammatory syndrome.
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Affiliation(s)
- Narendran Gopalan
- Division of HIV, National Institute for Research in Tuberculosis (Formerly Tuberculosis Research Centre), No. 1, Mayor Sathyamoorthy Road, Chetpet, Chennai, 600 031 India
| | - Padmapriyadarsini Chandrasekaran
- Division of HIV, National Institute for Research in Tuberculosis (Formerly Tuberculosis Research Centre), No. 1, Mayor Sathyamoorthy Road, Chetpet, Chennai, 600 031 India
| | - Soumya Swaminathan
- Division of HIV, National Institute for Research in Tuberculosis (Formerly Tuberculosis Research Centre), No. 1, Mayor Sathyamoorthy Road, Chetpet, Chennai, 600 031 India
| | - Srikanth Tripathy
- Division of HIV, National Institute for Research in Tuberculosis (Formerly Tuberculosis Research Centre), No. 1, Mayor Sathyamoorthy Road, Chetpet, Chennai, 600 031 India
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Narendran G, Kavitha D, Karunaianantham R, Gil-Santana L, Almeida-Junior JL, Reddy SD, Kumar MM, Hemalatha H, Jayanthi NN, Ravichandran N, Krishnaraja R, Prabhakar A, Manoharan T, Nithyananthan L, Arjunan G, Natrajan M, Swaminathan S, Andrade BB. Role of LTA4H Polymorphism in Tuberculosis-Associated Immune Reconstitution Inflammatory Syndrome Occurrence and Clinical Severity in Patients Infected with HIV. PLoS One 2016; 11:e0163298. [PMID: 27643598 PMCID: PMC5028072 DOI: 10.1371/journal.pone.0163298] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 09/03/2016] [Indexed: 11/24/2022] Open
Abstract
Background Paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is an inflammatory phenomenon complicating HIV management in coincidental tuberculosis (TB) infection, upon immune reconstitution driven by antiretroviral therapy (ART). Leukotriene A4 hydroxylase (LTA4H), an enzyme which converts LTA4 to LTB4, regulates the balance between the anti-inflammatory lipoxins and pro-inflammatory LTB4, with direct implications in TB-driven inflammation. In humans, a single nucleotide polymorphism (SNP) in the LTA4H promoter which regulates its transcriptional activity (rs17525495) has been identified and described to impact clinical severity of TB presentation and response to corticosteroid therapy. Notably, the role of LTA4H on TB-IRIS has not been previously evaluated. Here, we performed an exploratory investigation testing the association of LTA4H polymorphism with respect to frequency of TB-IRIS occurrence and severity of TB-IRIS presentation in HIV-TB co-infected individuals. Methods Genotypic evaluation of the LTA4H enzyme from available samples was retrospectively correlated with clinical data captured in case sheets including IRIS details. The cohort included patients recruited from a prospective cohort study nested within a randomized clinical trial (NCT0933790) of ART-naïve HIV+ patients with newly diagnosed rifampicin sensitive pulmonary TB in South India. Frequency of the wild type genotype (CC), as well as of the mutant genotypes (CT or TT) in the IRIS and non-IRIS patients was estimated. Comparative analyses were performed between wild genotype (CC) and the mutant genotypes (CT or TT) and tested for association between the LTA4H polymorphisms and IRIS incidence and clinical severity. Results A total of 142 eligible ART-naïve patients were included in the analyses. Eighty-six individuals exhibited the wild genotype (CC) while 56 had mutant genotypes (43-CT and only 13-TT). Variant allele frequency was 0.23 and 0.26 in non-IRIS group and in IRIS group, respectively. Upon ART initiation, 51 patients developed IRIS while 91 did not. IRIS incidence was 34% and 37% in the wild (CC) and mutant type (CT/TT), respectively (p = 0.858) with a higher frequency of severe IRIS presentation in the mutant genotype group compared to the wild type genotype (p = 0.0006). A logistic regression model confirmed the association between the presence of CT/TT genotypes and occurrence of severe IRIS. Corticosteroid therapy successfully resolved IRIS in all cases irrespective of the LTA4H genotype. Conclusion A higher incidence of severe IRIS among patients with mutant LTA4H genotypes (CT and TT) was observed compared to the wild type, despite similar IRIS incidence and immune restoration in both groups. Steroids were effective in alleviating IRIS in all the genotypes.
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Affiliation(s)
| | | | | | - Leonardo Gil-Santana
- Unidade de Medicina Investigativa, Laboratótio Integrado de Microbiologia e Imunorregulação, Centro de Pesquisas Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, Brazil
- Curso de Medicina, Faculdade de Tecnologia e Ciências, Salvador, Brazil
| | - Jilson L. Almeida-Junior
- Unidade de Medicina Investigativa, Laboratótio Integrado de Microbiologia e Imunorregulação, Centro de Pesquisas Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, Brazil
- Curso de Medicina, Faculdade de Tecnologia e Ciências, Salvador, Brazil
| | | | | | | | | | | | - Raja Krishnaraja
- Government Hospital of Thoracic Medicine, Tambaram Sanatorium, Chennai, India
| | | | | | | | | | - Mohan Natrajan
- National Institute for Research in Tuberculosis, Chennai, India
| | - Soumya Swaminathan
- National Institute for Research in Tuberculosis, Chennai, India
- India Council of Medical Research, Health secretary, Department of Health Research, Ministry of Health and Family Welfare, New Delhi, India
| | - Bruno B. Andrade
- Unidade de Medicina Investigativa, Laboratótio Integrado de Microbiologia e Imunorregulação, Centro de Pesquisas Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, Brazil
- Curso de Medicina, Faculdade de Tecnologia e Ciências, Salvador, Brazil
- * E-mail:
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40
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Vernon LT, Jayashantha P, Chidzonga MM, Komesu MC, Nair RG, Johnson NW. Comorbidities associated with HIV and antiretroviral therapy (clinical sciences): a workshop report. Oral Dis 2016; 22 Suppl 1:135-48. [PMID: 27109282 PMCID: PMC5986297 DOI: 10.1111/odi.12412] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 10/23/2015] [Accepted: 10/24/2015] [Indexed: 12/23/2022]
Abstract
In the era of combination antiretroviral therapy (ART), parsing out the effects of HIV vs ART on health outcomes is challenging. Nadir CD4 count, a marker of the extent of immunosuppression, has significant long-term impact on an array of disease states in HIV+ persons; however, in the dental literature, reporting of pre-ART exposure to immunosuppression has largely been ignored and this limits the validity of previous studies. In Workshop A1, we explain fully the importance of nadir CD4, pre-ART immunosuppression, and identify a need to include specific variables in future research. The questions posed herein are challenging, typically not neatly addressed by any one study and require integration of the latest evidence from the wider medical literature. We consider topics beyond the confines of the oral cavity and examine oral health in the complex context of ART era HIV immunopathophysiology. We depict how variability in geographic setting and time period (pre- and post-ART era) can impact oral conditions - influencing when HIV infection was detected (at what CD4 count), the type and timing of ART as well as social determinants such as strong stigma and limited access to care. We hope our Workshop will stir debate and energize a rigorous focus on relevant areas of future research in HIV/AIDS.
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Affiliation(s)
- L T Vernon
- Department of Biological Sciences, Case Western Reserve University School of Dental Medicine, Cleveland, OH, USA
| | - Plp Jayashantha
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Qld, Australia and Dental Hospital, and Sri Lanka Air Force Station Colombo, Sri Lanka, Australia
| | - M M Chidzonga
- College of Health Sciences, University of Zimbabwe, Avondale, Harare, Zimbabwe
| | - M C Komesu
- Department of Morphology, Stomatology Physiology, University of Sao Paulo, Ribeirao Preto, Sao Paulo, Brazil
| | - R G Nair
- Oral Medicine, School of Dentistry and Oral Health, Griffith University, Gold Coast, Qld, Australia and Cancer Services, Gold Coast University Hospital, Queensland Health, Qld, Autralia, Australia
| | - N W Johnson
- Menzies Health Institute, Griffith University, Gold Coast, Qld, Australia
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Namale PE, Abdullahi LH, Fine S, Kamkuemah M, Wilkinson RJ, Meintjes G. Paradoxical TB-IRIS in HIV-infected adults: a systematic review and meta-analysis. Future Microbiol 2016; 10:1077-99. [PMID: 26059627 DOI: 10.2217/fmb.15.9] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
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%).
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Affiliation(s)
- Phiona E Namale
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Leila H Abdullahi
- Vaccines for Africa Initiative, Institute of Infectious Disease & Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Stacey Fine
- Department of Medicine, New Somerset Hospital, Cnr Beach & Lower Portswood Road, Green Point, Cape Town 8001, Western Cape, South Africa
| | - Monika Kamkuemah
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Robert J Wilkinson
- Department of Medicine, University of Cape Town, Cape Town, South Africa.,Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease & Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa.,Department of Medicine, Imperial College London, W2 1PG, UK.,Medical Research Council, National Institute of Medical Research, London, NW7 1AA, UK
| | - Graeme Meintjes
- Department of Medicine, University of Cape Town, Cape Town, South Africa.,Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease & Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa.,Department of Medicine, Imperial College London, W2 1PG, UK
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Bell LCK, Breen R, Miller RF, Noursadeghi M, Lipman M. Paradoxical reactions and immune reconstitution inflammatory syndrome in tuberculosis. Int J Infect Dis 2016; 32:39-45. [PMID: 25809754 DOI: 10.1016/j.ijid.2014.12.030] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 12/15/2014] [Accepted: 12/16/2014] [Indexed: 12/01/2022] Open
Abstract
The coalescence of the HIV-1 and tuberculosis (TB) epidemics in Sub-Saharan Africa has had a significant and negative impact on global health. The availability of effective antimicrobial treatment for both HIV-1 (in the form of highly active antiretroviral therapy (HAART)) and TB (with antimycobacterial agents) has the potential to mitigate the associated morbidity and mortality. However, the use of both HAART and antimycobacterial therapy is associated with the development of inflammatory paradoxical syndromes after commencement of therapy. These include paradoxical reactions (PR) and immune reconstitution inflammatory syndromes (IRIS), conditions that complicate mycobacterial disease in HIV seronegative and seropositive individuals. Here, we discuss case definitions for PR and IRIS, and explore how advances in identifying the risk factors and immunopathogenesis of these conditions informs our understanding of their shared underlying pathogenesis. We propose that both PR and IRIS are characterized by the triggering of exaggerated inflammation in a setting of immunocompromise and antigen loading, via the reversal of immunosuppression by HAART and/or antimycobacterials. Further understanding of the molecular basis of this pathogenesis may pave the way for effective immunotherapies for the treatment of PR and IRIS.
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Affiliation(s)
- Lucy C K Bell
- Division of Infection and Immunity, Cruciform Building, University College London, Gower Street, London WC1E 6BT, UK.
| | - Ronan Breen
- Department of Respiratory Medicine, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Robert F Miller
- Research Department of Infection and Population Health, Institute of Epidemiology and Healthcare, University College London, London, UK
| | - Mahdad Noursadeghi
- Division of Infection and Immunity, Cruciform Building, University College London, Gower Street, London WC1E 6BT, UK
| | - Marc Lipman
- Centre for Respiratory Medicine, Royal Free London NHS Foundation Trust, University College London, London, UK
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Van Rie A, Sawry S, Link-Gelles R, Madhi S, Fairlie L, Verwey C, Mahomed N, Murdoch D, Moultrie H. Paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome in children. Pediatr Pulmonol 2016; 51:157-64. [PMID: 26073306 PMCID: PMC4678030 DOI: 10.1002/ppul.23221] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 04/06/2015] [Accepted: 04/19/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND Paradoxical tuberculosis (TB)-associated Immune Reconstitution Inflammatory Syndrome (IRIS) is a common complication of combination antiretroviral treatment (cART) initiation in adults residing in resource-limited regions. Little is known about the burden and presentation of TB-IRIS in children initiating cART while receiving TB treatment. METHODS Prospective cohort study of South African children initiating cART while on TB treatment. Children were assessed clinically and by chest x-ray before starting cART and at 2, 4, 6, and 12 weeks post cART initiation. All children who presented with any signs or symptoms suggestive of paradoxical TB-IRIS were classified according to the consensus adult TB-IRIS case definition developed by the International Network for Study of HIV-associated IRIS (INSHI) and reviewed by an independent expert panel. RESULTS In 7 of the 104 children enrolled in the cohort, symptoms and/or clinical or radiological signs suggestive of paradoxical TB-IRIS developed after a median of 14 days of cART. In two of these cases, there was agreement between the INSHI case definition and the expert panel. In an additional 3 cases, the INSHI criteria were fulfilled but the expert panel made an alternative diagnosis of pneumonia (n = 2) and poor adherence to cART (n = 1). CONCLUSIONS The burden of paradoxical TB-IRIS in children with underlying TB initiating cART is low. Including response to antibiotic treatment for pneumonia as a criterion for an alternative diagnosis may improve the specificity of the INSHI case definition.
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Affiliation(s)
- Annelies Van Rie
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Shobna Sawry
- University of the Witwatersrand, Faculty of Health Sciences, Wits Reproductive Health and HIV Institute, Johannesburg, South Africa
| | - Ruth Link-Gelles
- University of the Witwatersrand, Faculty of Health Sciences, Wits Reproductive Health and HIV Institute, Johannesburg, South Africa
| | - Shabir Madhi
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, University of the Witwatersrand, Johannesburg, South Africa.,National Research Foundation/Department of Science and Technology: Vaccine Preventable Diseases, University of the Witwatersrand, Johannesburg, South Africa
| | - Lee Fairlie
- University of the Witwatersrand, Faculty of Health Sciences, Wits Reproductive Health and HIV Institute, Johannesburg, South Africa
| | - Charl Verwey
- Division of Paediatric Pulmonology, Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Nasreen Mahomed
- Department of Diagnostic Radiology, University of the Witwatersrand, Johannesburg, South Africa
| | - David Murdoch
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Harry Moultrie
- University of the Witwatersrand, Faculty of Health Sciences, Wits Reproductive Health and HIV Institute, Johannesburg, South Africa
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Bigna JJR, Noubiap JJN, Agbor AA, Plottel CS, Billong SC, Ayong APR, Koulla-Shiro S. Early Mortality during Initial Treatment of Tuberculosis in Patients Co-Infected with HIV at the Yaoundé Central Hospital, Cameroon: An 8-Year Retrospective Cohort Study (2006-2013). PLoS One 2015. [PMID: 26214516 PMCID: PMC4516239 DOI: 10.1371/journal.pone.0132394] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background Understanding contributors to mortality during the initial phase of tuberculosis (TB) treatment in patients co-infected with HIV would guide targeted interventions to improve survival. The aim of this study was to ascertain the incidence of death during the initial 2 months (new cases) and 3 months (retreatment cases) of TB treatment and to assess correlates of mortality in HIV co-infected patients. Methods We conducted a hospital-based retrospective cohort study from January 2006 to December 2013 at Yaoundé Central Hospital, Cameroon. We reviewed medical records to identify co-infected TB/HIV inpatients aged 15 years and older who died during TB treatment. Death was defined as any death occurring during TB treatment, as per World Health Organization recommendations. We collected socio-demographic, clinical and laboratory data. We conducted multivariable logistic binary regression analysis to identify factors associated with death during the intensive phase of TB treatment. Magnitudes of associations were expressed by adjusted odds ratio (aOR) with 95% confidence interval. A p value < 0.05 was considered statistically significant. Results The 99 patients enrolled had a mean age of 39.5 (standard deviation 10.9) years and 53% were male. Patients were followed for 276.3 person-months of observation (PMO). Forty nine patients were died during intensive phase of TB treatment. Death incidence during the intensive phase of TB treatment was 32.2 per 100 PMO. Having a non-AIDS comorbidity (aOR 2.47, 95%CI 1.22-5.02, p = 0.012), having extra-pulmonary TB (aOR 1.89, 95%CI 1.05-3.43, p = 0.035), and one year increase in duration of known HIV infection (aOR 1.23, 95%CI 1.004-1.49) were independently associated with death during the intensive phase of TB treatment. Conclusions Mortality incidence during intensive phase of TB treatment was high among TB/HIV co-infected patients during TB treatment; and strongly associated with extra pulmonary TB suggesting advanced stage of immunosuppression and non-AIDS comorbidities. Early HIV diagnosis and care and good management of non-comorbidities can reduce this incidence.
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Affiliation(s)
- Jean Joel R. Bigna
- Department of Epidemiology and Public Health, Pasteur Center of Cameroon, Yaoundé, Cameroon
- * E-mail:
| | - Jean Jacques N. Noubiap
- Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
- Medical Diagnosis Center, Yaoundé, Cameroon
| | - Ako A. Agbor
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
| | - Claudia S. Plottel
- Department of Medicine, NYU-Langone Medical Center, New York, New York, United States of America
| | - Serge Clotaire Billong
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
- National AIDS control committee, Ministry of Public Health, Yaoundé, Cameroon
| | | | - Sinata Koulla-Shiro
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
- Infectious Diseases Unit, Yaoundé Central Hospital, Yaoundé, Cameroon
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Kim SB, Shrivastava MS, Strakhan M. A rare cause of acquired immune deficiency syndrome related pancytopenia. Hematol Rep 2015; 7:5475. [PMID: 25852844 PMCID: PMC4378201 DOI: 10.4081/hr.2015.5475] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 02/18/2015] [Indexed: 11/22/2022] Open
Abstract
A 21-year-old male with acquired immune deficiency syndrome, not on highly active antiretroviral treatment (HAART) was admitted after complaining of headache and intermittent diarrhea, found to have Cryptococcal meningitis. During the course of his hospitalization, patient developed pancytopenia. Anemia panel, serologies including Epstein barr virus, cytomegalovirus, and parvovirus were negative. Patient then developed high grade fever with elevated liver enzymes. Blood cultures, urine cultures, stool cultures, and repeat cerebrospinal fluid cultures remained negative. Patient subsequently developed skin lesions which on biopsy showed Kaposi’s sarcoma, and upon endoscopy, noted to have gastrointestinal Kaposi’s sarcoma involvement. Human herpes virus 8 was positive. Bone marrow biopsy revealed hemophagocytic lymphohistiocytosis. Despite having a concern for patient developing immune reconstitution syndrome which may worsen his meningitis, HAART was initiated and patient’s symptoms improved including resolution of fevers and hematological as well as liver abnormalities. Kaposi’s sarcoma improved as well.
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Affiliation(s)
- Su Bin Kim
- Department of Medicine, Albert Einstein College of Medicine , Jacobi Medical Center, Bronx, NY, USA
| | | | - Marianna Strakhan
- Department of Hematology/Oncology, Albert Einstein College of Medicine , Jacobi Medical Center, Bronx, NY, USA
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Walker NF, Scriven J, Meintjes G, Wilkinson RJ. Immune reconstitution inflammatory syndrome in HIV-infected patients. HIV AIDS (Auckl) 2015; 7:49-64. [PMID: 25709503 PMCID: PMC4334287 DOI: 10.2147/hiv.s42328] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Access to antiretroviral therapy (ART) is improving worldwide. Immune reconstitution inflammatory syndrome (IRIS) is a common complication of ART initiation. In this review, we provide an overview of clinical and epidemiological features of HIV-associated IRIS, current understanding of pathophysiological mechanisms, available therapy, and preventive strategies. The spectrum of HIV-associated IRIS is described, with a particular focus on three important pathogen-associated forms: tuberculosis-associated IRIS, cryptococcal IRIS, and Kaposi's sarcoma IRIS. While the clinical features and epidemiology are well described, there are major gaps in our understanding of pathophysiology and as a result therapeutic and preventative strategies are suboptimal. Timing of ART initiation is critical to reduce IRIS-associated morbidity. Improved understanding of the pathophysiology of IRIS will hopefully enable improved diagnostic modalities and better targeted treatments to be developed.
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Affiliation(s)
- Naomi F Walker
- Department of Medicine, Imperial College London, London, UK
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - James Scriven
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Graeme Meintjes
- Department of Medicine, Imperial College London, London, UK
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Robert J Wilkinson
- Department of Medicine, Imperial College London, London, UK
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- MRC National Institute of Medical Research, London, UK
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Ogola GO, Ouma C, Jura WGZO, Muok EO, Colebunders R, Mwinzi PN. A non-synonymous polymorphism in IL-23R Gene (rs1884444) is associated with reduced risk to schistosomiasis-associated Immune Reconstitution Inflammatory Syndrome in a Kenyan population. BMC Infect Dis 2014; 14:316. [PMID: 24912586 PMCID: PMC4057813 DOI: 10.1186/1471-2334-14-316] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 05/29/2014] [Indexed: 11/10/2022] Open
Abstract
Background Human Immunodeficiency Virus (HIV) and Schistosomiasis co-infection is common among residents at the shores of Lake Victoria in Kenya. About 36% of this population initiating antiretroviral therapy (ART) experience Immune Reconstitution Inflammatory Syndrome (IRIS) that complicates recovery. Several IL-23R alleles have been associated with susceptibility to both autoimmune and inflammatory diseases through T-helper type 17 (TH17) cells. However, whether or not variants within the IL-23R increase susceptibility to IRIS in western Kenya is unknown. The objective of the current study was to determine the association between IL-23R gene polymorphisms, CD4+ cell counts and HIV RNA levels and IRIS in HIV and Schistosoma mansoni co-infected patients undergoing highly active anti-retroviral therapy (HAART). Methods A three-month case–control study was conducted on antiretroviral naïve schistosomiasis/HIV co-infected fishermen starting HAART in Uyoma Rarieda, Siaya County, Kenya. Seventy one patients were sampled at baseline and followed up for three months, to establish if they developed Schistosoma-related IRIS. In addition, the CD4+ cell counts and HIV RNA levels were determined in pre- and post-administration of HAART. Variations at five polymorphic sites of IL-23R (rs1884444, rs11465754, rs6682925, rs7530511 and rs7539625) based on >10% minor allele frequency in Yoruban reference population was determined using Allelic Discrimination Assay. The association between the five variants and susceptibility to IRIS was determined using logistic regression while controlling for potential confounders. In addition, the functional differences between the baseline CD4 + Cell counts and viral loads were determined using medians while across IL-23R genotypes were determined using Kruskal-Wallis tests. Results Overall, 26 (36.6%) patients developed schistosomiasis-associated IRIS at a median age of 35.5 years. Carriage of the TT genotype at the non-synonymous rs1884444 T > G relative to GG, was associated with a decreased risk of schistosomiasis-associated IRIS (OR, 0.25, 95% CI, 0.07-0.96, P = 0.043) while both baseline CD4+ cell counts and viral loads had no association with IRIS. Conclusion These findings indicate that the non-synonymous variant rs1884444 T > G of IL-23R is associated with a decreased risk to schistosomiasis-associated IRIS. However, additional studies in a larger cohort and with an all inclusive polymorphic variants in the synonymous and non-synonymous regions need to be evaluated.
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Tuberculosis Immune Reconstitution Inflammatory Syndrome in children initiating Antiretroviral Therapy for HIV infection: A systematic literature review. Pediatr Infect Dis J 2014; 33:499-503. [PMID: 24736441 PMCID: PMC4121969 DOI: 10.1097/inf.0000000000000142] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND People with HIV initiating combination antiretroviral therapy are at risk for tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS). While this syndrome has been well researched in adults, little is known about the incidence, case fatality, underlying immunopathology and treatment approaches in children. METHODS Major databases were searched for articles related to TB-IRIS in children. Data were abstracted using standardized forms. RESULTS Thirteen studies were identified: 6 retrospective and 2 prospective cohort studies, 1 cross-sectional study, 3 case reports and 1 case series. In total, 303 cases of TB-IRIS were described, of which 270 were unmasking TB-IRIS, 12 paradoxical TB-IRIS and 21 were not classifiable due to lack of key information. None of the cohort studies had investigation of TB-IRIS as its primary aim. Nine studies were from Africa, 3 from Asia and 1 from Latin America. Age at cART initiation (reported by 12 studies) ranged from 1 month to 16 years. Median time from start of cART to IRIS diagnosis (reported by 8 studies) ranged from 8 days to 16 weeks. Few deaths attributable to TB-IRIS were recorded. Treatment was only discussed in 2 case studies, both of which reported children receiving corticosteroids. No studies evaluated risk factors for, or immunopathogenesis of, pediatric TB-IRIS. CONCLUSIONS There is a paucity of information available on TB-IRIS in children. Future research assessing incidence, risk factors, case fatality and optimal treatment or prevention strategies of TB-IRIS is needed.
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Tuberculosis immune reconstitution inflammatory syndrome in A5221 STRIDE: timing, severity, and implications for HIV-TB programs. J Acquir Immune Defic Syndr 2014; 65:423-8. [PMID: 24226057 DOI: 10.1097/qai.0000000000000030] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
RATIONALE AND OBJECTIVES Earlier initiation of antiretroviral therapy (ART) in HIV-tuberculosis (TB) is associated with increased immune reconstitution inflammatory syndrome (IRIS). The severity, frequency, and complications of TB IRIS were evaluated in A5221, a randomized trial of earlier ART (within 2 weeks after TB treatment initiation) vs. later ART (8-12 weeks after TB treatment) in HIV-infected patients starting TB treatment. METHODS AND MEASUREMENTS In 806 participants, TB IRIS was defined using published clinical criteria. Cases were classified as severe (hospitalization/death), moderate (corticosteroid use/invasive procedure), or mild (no hospitalization/procedures/steroids). Fisher exact, Wilcoxon, and log-rank tests were used for comparisons. MAIN RESULTS TB IRIS occurred in 61 (7.6%) patients: 10.4% in earlier vs. 4.7% in later ART, 11.5% with CD4 <50 vs. 5.4% with CD4 ≥50 cells per cubic millimeter. The CD4/ART arm interaction was significant, P = 0.014, with 44.3% of TB IRIS occurring with CD4 <50 and earlier ART. TB IRIS occurred sooner with earlier vs. later ART initiation, at a median of 29 vs. 82 days after TB treatment initiation (P < 0.001). IRIS manifestations included lymphadenopathy (59.0%), constitutional symptoms (54.1%), and radiographic changes (41.0%); central nervous system TB IRIS was uncommon (6.6%). TB IRIS was mild in 27.9%, moderate in 41.0%, and severe in 31.1%. No TB IRIS-associated deaths occurred. IRIS management required ≥1 invasive procedures in 34.4%, hospitalization in 31.1%, and corticosteroids in 54.1%. CONCLUSIONS TB IRIS was more frequent with earlier ART initiation and CD4 <50 cells per cubic millimeter. As ART is implemented earlier in HIV-TB coinfection, programs will require the diagnostic capabilities, clinical resources, and training necessary to manage TB IRIS.
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