Coexistent sarcoidosis and HIV infection. A comparison of bronchoalveolar and peripheral blood lymphocytes

A novel immunogen to modulate cytokine production and promote immune system reconstitution in HIV-AIDS

This 'proof of concept' study was implemented in anticipation of identifying and testing a novel antigen of human origin as a potential immunogen in a paradigm that emphasizes immunomodulation and immune system reconstitution as requisites to the development of an effective human immunodeficiency virus (HIV)-acquired immune deficiency syndrome vaccine. Fifteen HIV-infected, highly active antiretroviral therapy (HAART) naive, otherwise healthy male seropositive patients were stratified by [CD4+] into 3 groups of 5 patients: group 1 >500/mm; group 2 > 250/mm but <500/mm; and group 3 < 250/mm. Five healthy male subjects were used as controls. Replicate peripheral blood mononuclear cell (PBMC) [H]thymidine uptake phytohemaglutinin-stimulated proliferation studies, and serum cytokine assays were carried out in the presence or absence of Kveim antigen at dilutions ranging from 0.001 to 100 μg/mL. Serum cytokines [interleukin-2 (IL-2), IL-4, IL-6, interferon gamma, and tumor necrosis factor alpha] were assayed using standardized methodology. Nonparametric statistical analyses and linear regression analysis were used to test for statistical significance and strength of associations. PBMCs harvested from HIV-infected patients and incubated, ex vivo, demonstrated reproducible, antigen concentration-dependent changes in cytokine production over a range of antigen concentrations (0.001-100 μg/mL) in contrast to antigen-naive PBMCs and controls. Significant correlations were demonstrated between antigen concentration and the amount of cytokines secreted. The magnitude of the cytokine response and the patterns of cytokine secretion were HIV group-specific and could be used to identify and distinguish between the 3 groups of HIV-infected subjects. A shift toward the production of type 1-like (Th1) cytokines characteristically seen in systemic sarcoidosis and associated with effective HAART was seen when patterns of cytokine secretion were compared between antigen exposed and antigen-naive PBMCs. PBMCs harvested from seropositive HIV-infected patients and exposed to the Kveim antigen have the following properties: (1) They demonstrate proliferation and exhibit an antigen concentration-dependent secretion of cytokines. The magnitude of the cytokine response can be used to identify and distinguish between groups of seropositive patients stratified by [CD4+]. (2) These PBMCs secrete cytokines in patterns suggestive of a shift to a type 1-like (Th1) response characteristic of HAART and sarcoidosis as opposed to the type 2-like (Th2) cytokine profile characteristic of HIV-acquired immune deficiency syndrome.

Pulmonary manifestations of the immune reconstitution inflammatory syndrome

PURPOSE OF REVIEW

Immune reconstitution inflammatory syndrome (IRIS) is a common occurrence in HIV patients starting antiretroviral therapy (ART), and pulmonary involvement is an important feature of tuberculosis-IRIS and pneumocystis-IRIS. Pulmonologists need an awareness of the timing, presentation and treatment of pulmonary IRIS.

RECENT FINDINGS

Case definitions for tuberculosis-IRIS and cryptococcal-IRIS have been published by the International Network for the Study of HIV-associated IRIS (INSHI). A number of studies have addressed validation of clinical case definitions and the optimal time to commence ART after diagnosis of an opportunistic infection in HIV patients. The pathogenesis of IRIS is being assessed at a molecular level, increasing our understanding of mechanisms and possible targets for future preventive and therapeutic strategies.

SUMMARY

Tuberculosis-IRIS, nontuberculosis mycobacterial-IRIS and pneumocystis-IRIS occur within days to weeks of starting ART, causing substantial morbidity, but low mortality. Cryptococcal-IRIS usually occurs later in the course of ART, and may be associated with appreciable mortality. Early recognition of unmasking and paradoxical IRIS affecting the lung allows timely initiation of antimicrobial and/or immunomodulatory therapies.

Sarcoidosis in HIV‐Infected Patients in the Era of Highly Active Antiretroviral Therapy

To analyze the impact of highly active antiretroviral therapy (HAART) on the characteristics and outcome of sarcoidosis in patients infected with human immunodeficiency virus (HIV), we identified HIV-infected patients in whom sarcoidosis was diagnosed between 1996 and 2000 from the admission registers of the pneumology departments of 12 hospitals in the Paris region (France). Sarcoidosis was diagnosed in 11 HIV-infected patients, of whom 8 were receiving HAART. HIV infection was diagnosed before sarcoidosis in 9 cases. At diagnosis of sarcoidosis, the mean CD4 cell count (+/-SD) was 390+/-213 cells/mm(3), and the mean plasma virus load was 4002+/-10,183 copies/mL. Sarcoidosis occurred several months after HAART introduction, when the CD4 cell count had increased and the plasma HIV load had decreased. Clinical and radiological characteristics, laboratory values for bronchoalveolar lavage fluid samples, and outcome after a long follow-up were similar for the patients receiving HAART and for HIV-uninfected patients.

Sarcoidosis following HIV infection: evidence for CD4+ lymphocyte dependence

BACKGROUND

The chronic granulomatous inflammation of sarcoidosis has been hypothesized to depend on the CD4+ T-helper lymphocyte. HIV infection, which depletes these cells, has been reported to attenuate the manifestations of sarcoidosis.

STUDY OBJECTIVES

We asked whether the development of symptomatic sarcoidosis in the context of preexisting HIV infection was dependent on the CD4+ lymphocyte count.

DESIGN

We performed a retrospective standardized chart review of all patients who developed granulomatous inflammation following HIV infection at an urban academic referral center.

MEASUREMENTS

We identified seven patients with sarcoidosis within this cohort and compared their CD4+ lymphocyte count to that in a cohort of 16 patients in whom similar granulomatous inflammation was found but who did not have sarcoidosis. We then compared our cases to all reported cases using a systematic literature review.

RESULTS

The CD4+ lymphocyte count was > 200 cells/ microL in all of our patients with HIV infection when they developed subsequent sarcoidosis. In contrast, specific etiologies for granulomatous inflammation were found in all 10 HIV-infected patients who presented with granulomatous inflammation and a CD4+ lymphocyte count of < 200 cells/ microL, with infectious etiologies found in 8 patients. Similarly, there was relative preservation of the CD4+ lymphocyte count in previously reported cases, with 14 of 19 patients (74%) having an absolute CD4+ lymphocyte count of > 200 cells/ microL.

CONCLUSIONS

We conclude that the development of the chronic granulomatous inflammation of sarcoidosis appears to depend on the preservation or restoration of the peripheral CD4+ lymphocyte count and that in most cases the CD4+ lymphocyte count exceeds 200 cells/ microL. Furthermore, alternative specific etiologies of granulomatous inflammation are generally identifiable in HIV-infected patients with peripheral CD4+ lymphocyte counts of < 200 cells/ microL.

Recurrent pulmonary sarcoidosis in HIV-infected patients receiving highly active antiretroviral therapy

HIV infection and sarcoidosis occur in the same age group, but there are only a few reports of the coexistence of the two disorders in the same individual. This infrequent occurrence has been attributed to the paucity of functioning CD4(+) lymphocytes required for granuloma formation in patients with HIV infection. We report two patients with a history of remote sarcoidosis who later in life contracted HIV infection and developed recurrent, progressive pulmonary sarcoidosis while receiving highly active antiretroviral therapy (HAART). Progressive pulmonary sarcoidosis should be added to the differential diagnosis in patients receiving HAART for HIV infection who develop diffuse lung disease with recovery of CD4(+) lymphocyte population.

Newly diagnosed pulmonary sarcoidosis in HIV-infected patients

PURPOSE

To determine the radiologic and clinical features of newly diagnosed pulmonary sarcoidosis in human immunodeficiency virus (HIV)-infected patients.

MATERIALS AND METHODS

Ten HIV-infected patients (seven women, three men; age range, 26-66 years; mean age, 37 years) with newly diagnosed sarcoidosis between 1989 and 1997 were retrospectively identified. Charts were reviewed for the interval between the two diagnoses, CD4 cell count, signs or symptoms, angiotensin-converting enzyme level, and initiation of highly active antiretroviral therapy (HAART). Chest radiographs (n = 10) and computed tomographic (CT) scans (n = 8) were assessed for lymphadenopathy, pulmonary nodules, focal consolidation, reticular or granular opacities (thickened interlobular septa and ground-glass opacities at CT), cysts or cavities, and fibrosis.

RESULTS

Mean interval between the two diagnoses was 3 years. Mean CD4 cell count was 213 cells per cubic millimeter. When sarcoidosis was diagnosed, eight patients had pulmonary signs or symptoms. The angiotensin-converting enzyme level was elevated in five of six patients; two developed sarcoidosis after beginning HAART. Chest radiographs revealed lymphadenopathy, pulmonary nodules, focal consolidation, reticular opacities, granular opacities, and cysts or cavities. Chest CT scans revealed lymphadenopathy, nodules, thickened interlobular septa, focal consolidation, reticular opacities, ground-glass opacities, and cysts or cavities. There was no relationship between the radiographic findings of sarcoidosis and the CD4 cell count.

CONCLUSION

The radiologic features of newly diagnosed sarcoidosis in HIV-infected patients resemble the findings of sarcoidosis in non-HIV-infected patients. In HIV-infected patients receiving HAART, sarcoidosis may be a manifestation of disease related to restoration of the immune system.

Sarcoid-like pulmonary disorder in human immunodeficiency virus-infected patients receiving antiretroviral therapy

We report two cases of HIV-infected patients who presented with diffuse interstitial micronodular lesions on chest X-ray after institution of protease inhibitor-containing highly active antiretroviral therapy (HAART). Granulomatous pulmonary disorder mimicking sarcoidosis was diagnosed on histopathological studies revealing noncaseating granuloma and bronchoalveolar lavage analysis showing an intense CD4(+) lymphocyte alveolitis. Causative agents such as infectious organisms and environmental compounds were excluded. The relationship between sarcoid-like reaction and immune reconstitution under HAART is discussed.

Pneumocystis carinii in a patient with pulmonary sarcoidosis and idiopathic CD4+ T lymphocytopenia

A case of pulmonary sarcoidosis and idiopathic CD4+ T lymphocytopenia is reported. Pneumocystis carinii was detected in the bronchoalveolar lavage fluid of a young homosexual man who was asymptomatic without any evidence of congenital or acquired immunodeficiency but with a low CD4+ cell count. A clinical and histological diagnosis of pulmonary sarcoidosis was made. During follow up the patient had oral candidiasis and a CD4+ cell count persistently below 300/microliters. This case is highly suggestive of concurrent pulmonary sarcoidosis and idiopathic CD4+ T lymphocytopenia.