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Abdeljaleel F, Azar J, Ayasa LA, Rabaia D. Kaposi sarcoma-induced immune reconstitution syndrome: a case report. Ann Med Surg (Lond) 2024; 86:2242-2247. [PMID: 38576974 PMCID: PMC10990315 DOI: 10.1097/ms9.0000000000001842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/08/2024] [Indexed: 04/06/2024] Open
Abstract
Introduction and importance Kaposi sarcoma (KS) is an angioproliferative disease, that mostly affects HIV-infected patients with a high viral load and a low CD4 count. In rare cases, the paradoxical worsening of a pre-existing or previously unrecognized opportunistic infection occurs in a phenomenon known as immune reconstitution inflammatory response (IRIS). Case presentation The authors presented a male patient in his 30s with HIV, who developed a series of complications caused by KS following the initiation of antiretroviral therapy. Despite ongoing antiretroviral therapy (ART), chemotherapy, and supportive measures, the patient developed KS-related IRIS, characterized by rapid clinical deterioration, multiorgan failure, and ultimately succumbed to the disease. Clinical discussion To the best of our knowledge, very rare cases have been reported with KS-IRIS after the initiation of ART. Many predictors of KS-IRIS development have been identified. Patients must meet the known diagnostic criteria to be diagnosed with IRIS. The treatment of KS-IRIS depends on the stage of KS. ART alone is usually adequate in mild cutaneous KS. Chemotherapy and ART are recommended for patients with severe cutaneous and visceral KS. Conclusion HIV patients with KS undergoing ART initiation or modification should be closely monitored, particularly during the early stages and in those with extensive disease. Treating opportunistic infections before ART initiation may reduce the risk of KS-IRIS. The increasing prevalence of KS in ART-treated patients with HIV warrants further attention and highlights the need for better management strategies in this population.
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Affiliation(s)
| | - Jehad Azar
- Mayo Clinic Health System, Cleveland, Ohio
| | | | - Dima Rabaia
- Faculty of Medicine and Health Science, An-Najah National University, Nablus, Palestine
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Górecka A, Majewski S, Szymańska E, Walecka I. Skin and mucosal manifestations of immune reconstitution inflammatory syndrome in people living with HIV: a review. Int J Dermatol 2024. [PMID: 38426349 DOI: 10.1111/ijd.17082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 01/15/2024] [Accepted: 01/29/2024] [Indexed: 03/02/2024]
Abstract
Opportunistic infections have significantly decreased in individuals living with human immunodeficiency virus and receiving antiretroviral therapy. However, in approximately 10%-25% of patients, severe skin reactions during immune reconstruction are constantly increasing. This may manifest as either an exacerbation of a chronic disease or the development of a new disorder, referred to as immune reconstitution inflammatory syndrome. This review focuses on the current knowledge regarding the dermatological symptoms of immune reconstitution inflammatory syndrome observed in recent years. These symptoms encompass various pathogens, neoplasms, and certain autoimmune diseases. In addition to the most common skin reactions, attention is directed towards conditions not previously described in any review, such as psoriasis.
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Affiliation(s)
- Aleksandra Górecka
- Department of Dermatology, National Medical Institute of the Ministry of the Interior and Administration, Warsaw, Poland
| | - Sławomir Majewski
- Department of Dermatology and Venereology, Medical University of Warsaw, Warsaw, Poland
| | - Elżbieta Szymańska
- Department of Dermatology, National Medical Institute of the Ministry of the Interior and Administration, Warsaw, Poland
- Department of Dermatology and Pediatric Dermatology, Centre of Postgraduate Medical Education in Warsaw, Warsaw, Poland
| | - Irena Walecka
- Department of Dermatology, National Medical Institute of the Ministry of the Interior and Administration, Warsaw, Poland
- Department of Dermatology and Pediatric Dermatology, Centre of Postgraduate Medical Education in Warsaw, Warsaw, Poland
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Rodrigues Alves N, Barão C, Mota C, Costa L, Proença RP. Immune recovery uveitis: a focus review. Graefes Arch Clin Exp Ophthalmol 2024:10.1007/s00417-024-06415-y. [PMID: 38381160 DOI: 10.1007/s00417-024-06415-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 12/23/2023] [Accepted: 02/11/2024] [Indexed: 02/22/2024] Open
Abstract
Immune recovery uveitis (IRU) is an intraocular inflammation that typically occurs as part of immune reconstitution inflammatory syndrome (IRIS) in the eye. Typically, it affects human immunodeficiency virus (HIV)-infected patients with recognized or unrecognized cytomegalovirus (CMV) retinitis who are receiving highly active antiretroviral therapy (HAART). IRU is a common cause of new vision loss in these patients, and it manifests with a wide range of symptoms and an increased risk of inflammatory complications, such as macular edema. Recently, similar IRU-like responses have been observed in non-HIV individuals with immune reconstitution following immunosuppression of diverse etiologies, posing challenges in diagnosis and treatment. This review provides an updated overview of the current literature on the epidemiology, pathophysiology, biomarkers, clinical manifestations, diagnosis, differential diagnosis, and treatment strategies for IRU.
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Affiliation(s)
- Nuno Rodrigues Alves
- Department of Ophthalmology, Unidade Local de Saúde de São José, Centro Hospitalar Universitário Lisboa Central, Rua José António Serrano, 1150-199, Lisbon, Portugal.
| | - Catarina Barão
- Department of Ophthalmology, Unidade Local de Saúde de São José, Centro Hospitalar Universitário Lisboa Central, Rua José António Serrano, 1150-199, Lisbon, Portugal
| | - Catarina Mota
- Department of Ophthalmology, Unidade Local de Saúde de São José, Centro Hospitalar Universitário Lisboa Central, Rua José António Serrano, 1150-199, Lisbon, Portugal
| | - Lívio Costa
- Department of Ophthalmology, Unidade Local de Saúde de São José, Centro Hospitalar Universitário Lisboa Central, Rua José António Serrano, 1150-199, Lisbon, Portugal
- NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Rita Pinto Proença
- Department of Ophthalmology, Unidade Local de Saúde de São José, Centro Hospitalar Universitário Lisboa Central, Rua José António Serrano, 1150-199, Lisbon, Portugal
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Rajme-López S, Corral-Herrera EA, Tello-Mercado AC, Tepo-Ponce KM, Pérez-Meléndez RE, Rosales-Sotomayor Á, Figueroa-Ramos G, López-López K, Domínguez-Cherit JG, San-Martín-Morante O, Saeb-Lima M, Gamboa-Domínguez A, Ponce-de-León A, Crabtree-Ramírez B, Ramos-Cervantes P, Ruíz-Palacios GM. Clinical, molecular, and histological characteristics of severely necrotic and fatal mpox in HIV-infected patients. AIDS Res Ther 2023; 20:85. [PMID: 38012656 PMCID: PMC10683144 DOI: 10.1186/s12981-023-00580-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 11/08/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND This case series of 5 patients with severely necrotic mpox highlights the predominantly necrotic nature of lesions seen in cases of severe mpox as shown by skin and lung biopsy, as well as the extensive dissemination of the infection, as shown by polymerase chain reaction (PCR) assessment in different body sites. CASE PRESENTATIONS Patients were male, the median age was 37, all lived with HIV (2 previously undiagnosed), the median CD4+ cell count was 106 cells/mm3, and 2/5 were not receiving antiretroviral treatment. The most common complication was soft tissue infection. Skin and lung biopsies showed extensive areas of necrosis. Mpox PCR was positive in various sites, including skin, urine, serum, and cerebrospinal fluid. The initiation of antiretroviral treatment, worsened the disease, like that seen in immune reconstitution syndrome. Three patients died due to multiple organ failure, presumably associated with mpox since coinfections and opportunistic pathogens were ruled out. CONCLUSIONS Severely necrotic manifestations of mpox in people living with advanced and untreated HIV are related to adverse outcomes.
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Affiliation(s)
- Sandra Rajme-López
- Infectious Diseases Department, Instituto Nacional de Ciencias Médicas y Nutrición, "Salvador Zubirán" Vasco de Quiroga #15, Belisario Domínguez Sección XVI, Tlalpan, Ciudad de México, 14080, México
| | - Ever A Corral-Herrera
- Infectious Diseases Department, Instituto Nacional de Ciencias Médicas y Nutrición, "Salvador Zubirán" Vasco de Quiroga #15, Belisario Domínguez Sección XVI, Tlalpan, Ciudad de México, 14080, México
| | - Andrea C Tello-Mercado
- Infectious Diseases Department, Instituto Nacional de Ciencias Médicas y Nutrición, "Salvador Zubirán" Vasco de Quiroga #15, Belisario Domínguez Sección XVI, Tlalpan, Ciudad de México, 14080, México
| | - Karen M Tepo-Ponce
- Infectious Diseases Department, Instituto Nacional de Ciencias Médicas y Nutrición, "Salvador Zubirán" Vasco de Quiroga #15, Belisario Domínguez Sección XVI, Tlalpan, Ciudad de México, 14080, México
| | - Raúl E Pérez-Meléndez
- Internal Medicine Department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Ángela Rosales-Sotomayor
- Dermatology Department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Grecia Figueroa-Ramos
- Dermatology Department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Karla López-López
- Dermatology Department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Judith G Domínguez-Cherit
- Dermatology Department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Oswaldo San-Martín-Morante
- Pathology Department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Marcela Saeb-Lima
- Pathology Department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Armando Gamboa-Domínguez
- Pathology Department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Alfredo Ponce-de-León
- Infectious Diseases Department, Instituto Nacional de Ciencias Médicas y Nutrición, "Salvador Zubirán" Vasco de Quiroga #15, Belisario Domínguez Sección XVI, Tlalpan, Ciudad de México, 14080, México
| | - Brenda Crabtree-Ramírez
- Infectious Diseases Department, Instituto Nacional de Ciencias Médicas y Nutrición, "Salvador Zubirán" Vasco de Quiroga #15, Belisario Domínguez Sección XVI, Tlalpan, Ciudad de México, 14080, México
| | - Pilar Ramos-Cervantes
- Virology and Molecular Biology Laboratory, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Guillermo M Ruíz-Palacios
- Infectious Diseases Department, Instituto Nacional de Ciencias Médicas y Nutrición, "Salvador Zubirán" Vasco de Quiroga #15, Belisario Domínguez Sección XVI, Tlalpan, Ciudad de México, 14080, México.
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Santana MN, Ferrari R, Macedo AC, Marcusso RMN, Fernandes RDA, Vidal JE. Acquired immunodeficiency syndrome-related progressive multifocal leukoencephalopathy-immune reconstitution inflammatory syndrome: prevalence, main characteristics, and outcomes in a Brazilian center. Arq Neuropsiquiatr 2023; 81:883-890. [PMID: 37899047 PMCID: PMC10631851 DOI: 10.1055/s-0043-1772831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 06/07/2023] [Indexed: 10/31/2023]
Abstract
BACKGROUND Progressive multifocal leukoencephalopathy (PML) - immune reconstitution inflammatory syndrome (IRIS) in people living with HIV/AIDS (PLWHA) has been rarely described in low- and middle-income countries. OBJECTIVE To describe the prevalence of PML-IRIS among PLWHA with PML and its main features in a tertiary hospital in Brazil. METHODS We performed a retrospective cohort study. We included PLWHA with PML-IRIS patients admitted at Instituto de Infectologia Emílio Ribas, São Paulo, Brazil, between 2011 and 2021. We retrieved information on neurological manifestations, neuroimaging findings, treatments, and outcomes. RESULTS We identified 11 (11.8%) PML-IRIS cases among 93 patients with definite PML. Eight (73%) cases were men and had a median (IQR) age of 41 (27-50) years. Seven (63.6%) patients developed unmasking PML-IRIS and 4 (36.4%) had paradoxical PML-IRIS. The median (IQR) time from initiation of combined antiretroviral therapy (cART) to IRIS diagnosis was 49 (30-70) days. Ten (90.9%) patients received corticosteroids. There were 4 (36%) in-hospital deaths and 3 were associated with hospital-acquired pneumonia. Among the 7 (64%) patients who survived, 5 (71.5%) had sequelae at discharge. One year after the PML-IRIS diagnosis, 6 (54.5%) patients were alive. CONCLUSION The prevalence of PML-IRIS was 11.8%. Most patients had unmasking PML-IRIS. In-hospital mortality and morbidity were high. One-year survival was similar to that described in some high-income countries.
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Affiliation(s)
| | - Raphaela Ferrari
- Instituto de Infectologia Emílio Ribas, Departamento de Infectologia, São Paulo SP, Brazil.
| | - Arthur Cassa Macedo
- McGill University, Department of Neurology and Neurosurgery, Montreal QC, Canada.
| | | | | | - José Ernesto Vidal
- Instituto de Infectologia Emílio Ribas, Departamento de Neurologia, São Paulo SP, Brazil.
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Moléstias Infecciosas e Parasitárias, São Paulo SP, Brazil.
- Universidade de São Paulo, Faculdade de Medicina, Laboratório de Investigação Médica (LIM 49), São Paulo SP, Brazil.
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Bhattacharya D, Tierney C, Butler K, Kiweewa FM, Moodley D, Govender V, Vhembo T, Mohtashemi N, Ship H, Dula D, George K, Chaktoura N, Glenn Fowler M, Peters MG, Currier JS. Comparison of Antiretroviral Therapies in Pregnant Women Living With Human Immunodeficiency Virus and Hepatitis B Virus: A Randomized Controlled Trial. Obstet Gynecol 2023; 142:613-624. [PMID: 37535953 PMCID: PMC10527604 DOI: 10.1097/aog.0000000000005302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 04/04/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVE To describe the anti-hepatitis B virus (HBV) efficacy, HBeAg serologic changes, HBV perinatal transmission, and safety in pregnant women who are living with human immunodeficiency virus (HIV) and HBV co-infection who were randomized to various antiretroviral therapy (ART) regimens. METHODS The PROMISE (Promoting Maternal and Infant Survival Everywhere) trial was a multicenter randomized trial for ART-naive pregnant women with HIV infection. Women with HIV and HBV co-infection at 14 or more weeks of gestation were randomized to one of three ART arms: one without HBV treatment (group 1) and two HBV treatment arms with single (group 2) or dual anti-HBV activity (group 3). The primary HBV outcome was HBV viral load antepartum change from baseline (enrollment) to 8 weeks; safety assessments included alanine aminotransferase (ALT) level, aspartate aminotransferase (AST) level, and anemia (hemoglobin less than 10 g/dL). Primary comparison was for the HBV-active treatment arms. Pairwise comparisons applied t test and the Fisher exact tests. RESULTS Of 3,543 women, 3.9% were HBsAg-positive; 42 were randomized to group 1, 48 to group 2, and 48 to group 3. Median gestational age at enrollment was 27 weeks. Among HBV-viremic women, mean antepartum HBV viral load change at week 8 was -0.26 log 10 international units/mL in group 1, -1.86 in group 2, and -1.89 in group 3. In those who were HBeAg-positive, HBeAg loss occurred in 44.4% at delivery. Two perinatal HBV transmissions occurred in group 2. During the antepartum period, one woman (2.4%) in group 1 had grade 3 or 4 ALT or AST elevations, two women (4.2%) in group 2, and three women (6.3%) in group 3. CONCLUSION Over a short period of time, HBV DNA suppression was not different with one or two HBV-active agents. HbeAg loss occurred in a substantial proportion of participants. Perinatal transmission of HBV infection was low. Hepatitis B virus-active ART was well-tolerated in pregnancy, with few grade 3 or 4 ALT or AST elevations. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov , NCT01061151.
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Affiliation(s)
| | | | | | - Flavia Matovu Kiweewa
- MU-JHU Research Collaboration, Kampala, Uganda
- Makerere University School of Public Health, Kampala, Uganda
| | | | - Vani Govender
- Caprisa -University of KwazuluNatal
- University of Kwazulu-Natal, Durban, South Africa
| | | | | | | | - Dingase Dula
- Johns Hopkins Research Project, Blantyre, Malawi
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Leone F, Cotugno N, Casamento Tumeo C, Zangari P, Palomba P, Adorisio R, De Benedetti F, Bracaglia C, Papoff P, Ajassa C, Palma P, Bernardi S. Hyperinflammatory syndrome in a paediatric patient with a recent diagnosis of HIV/AIDS infection: hemophagocytic lymphohistiocytosis or immune reconstitution syndrome? BMC Infect Dis 2023; 23:477. [PMID: 37464267 DOI: 10.1186/s12879-023-08457-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 07/11/2023] [Indexed: 07/20/2023] Open
Abstract
INTRODUCTION Haemophagocytic lymphohistiocytosis is a rare and life-threatening condition caused by uncontrolled immune activation leading to excessive inflammation and tissue destruction. It could either be due to a primary genetic defect or be triggered by secondary causes such as infections, autoimmune diseases, rheumatological diseases or post-transplant immunosuppression. We here report the case of a 4-year-old child with a recent AIDS diagnosis who developed a severe systemic inflammation. CASE REPORT We here report the case of a 4-year-old child with a recent AIDS diagnosis who was admitted to the ER with acute respiratory failure due to Pneumocystis jiroveci infection and Aspergillosis; the following microbiological assessment also showed a CMV, HSV, EBV and HHV-7 coinfection. On the 51st day after she'd started antiretroviral therapy, 39th after she'd followed a course of Bactrim and Caspofungin for PJI and Ambisome for pulmonary Aspergillosis, she started presenting fever, unresponsive to broad-spectrum antibiotic therapy. She also presented worsening of her clinical conditions, with evidence at the laboratory assessments of progressive raise in inflammatory indexes, coagulopathy, trilinear cytopenia and hyperferritinemia. To perform the differential diagnosis between IRIS and HLH, HLA-DR on T cells was studied, turning out negative for IRIS. Therefore, in the suspicion of HLH, a bone marrow aspirate and biopsy were performed with evidence of trilinear cytopenia, prevalence of T-cells and macrophages with signs of phagocytosis. She was started on high-dose steroids and Anakinra for a total of 29 days, resulting in prompt apyrexia and progressive improvement of her clinical conditions and laboratory results. CONCLUSION To the best of our knowledge there is poor literature available about the differential diagnosis of HLH and IRIS, therefore medical management in the concurrence of these two conditions needs to be further investigated, especially in a setting where immunological testing is not quickly available. The clinical differences between these pathologies are blurred and the bone marrow biopsy within marker for IRIS helped us to distinguish these two entities.
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Affiliation(s)
- Fabrizio Leone
- Policlinico Umberto I, Maternal Infantile and Urological Sciences Department, Sapienza University of Rome, Rome, Italy.
| | - Nicola Cotugno
- Clinical and Research Unit of Clinical Immunology and Vaccinology, Academic Department of Pediatrics (DPUO), Bambino Gesù Children Hospital, IRCCS, Rome, Italy
- Chair of Pediatrics, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Chiara Casamento Tumeo
- Academic Department of Pediatrics (DPUO), Bambino Gesù Pediatric Hospital, IRCCS, Rome, Italy
| | - Paola Zangari
- Clinical and Research Unit of Clinical Immunology and Vaccinology, Academic Department of Pediatrics (DPUO), Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Patrizia Palomba
- Microbiology and Diagnostic Immunology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Rachele Adorisio
- Heart Failure, Transplant and Mechanical Cardiocirculatory Support Unit, Department of Pediatric Cardiology and Cardiac Surgery, Heart Lung Transplantation, ERN GUARD HEART: Bambino Gesù Hospital and Research Institute, Rome, Italy
| | | | - Claudia Bracaglia
- Division of Rheumatology, Bambino Gesù Children's Hospital, IRCCS, Roma, Italy
| | - Paola Papoff
- Department of Pediatrics, Pediatric Intensive Care Unit, Umberto I Policlinico, Sapienza University of Rome, Rome, Italy
| | - Camilla Ajassa
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Paolo Palma
- Clinical and Research Unit of Clinical Immunology and Vaccinology, Academic Department of Pediatrics (DPUO), Bambino Gesù Children Hospital, IRCCS, Rome, Italy
- Chair of Pediatrics, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Stefania Bernardi
- Unit of Immune and Infectious Disease, University Department of Pediatrics, DPUO, Bambino Gesù Children's Hospital, Rome, Italy
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Martinez AE, Frattaroli P, Vu CA, Paniagua L, Mintz J, Bravo-Gonzalez A, Zamudio P, Barco A, Rampersad A, Lichtenberger P, Gonzales-Zamora JA. Successful Outcome after Treatment with Cidofovir, Vaccinia, and Extended Course of Tecovirimat in a Newly-Diagnosed HIV Patient with Severe Mpox: A Case Report. Vaccines (Basel) 2023; 11:vaccines11030650. [PMID: 36992234 DOI: 10.3390/vaccines11030650] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/10/2023] [Accepted: 03/13/2023] [Indexed: 03/16/2023] Open
Abstract
Purpose: To report a case of severe mpox in a newly diagnosed HIV patient concerning for Immune Reconstitution Inflammatory Syndrome (IRIS) and/or tecovirimat resistance and to describe the management approach in the setting of refractory disease. Case: 49-year-old man presented with 2 weeks of perianal lesions. He tested positive for mpox PCR in the emergency room and was discharged home with quarantine instructions. Three weeks later, the patient returned with disseminated firm, nodular lesions in the face, neck, scalp, mouth, chest, back, legs, arms, and rectum, with worsening pain and purulent drainage from the rectum. The patient reported being on 3 days of tecovirimat treatment, which was prescribed by the Florida department of health (DOH). During this admission, he was found to be HIV positive. A pelvic CT scan revealed a 2.5 cm perirectal abscess. Treatment with tecovirimat was continued for 14 days, along with an empiric course of antibiotics for treatment of possible superimposed bacterial infection upon discharge. He was seen in the outpatient clinic and initiated antiretroviral therapy (ART) with TAF/emtricitabine/bictegravir. Two weeks after starting ART, the patient was readmitted for worsening mpox rash and rectal pain. Urine PCR also returned positive for chlamydia, for which the patient was prescribed doxycycline. He was discharged on a second course of tecovirimat and antibiotic therapy. Ten days later, the patient was readmitted for the second time due to worsening symptoms and blockage of the nasal airway from progressing lesions. At this point, there were concerns for tecovirimat resistance, and after discussion with CDC, tecovirimat was reinitiated for the third time, with the addition of Cidofovir and Vaccinia, and showed an improvement in his symptoms. He received three doses of cidofovir and two doses of Vaccinia, and the patient was then discharged to complete 30 days of tecovirimat. Outpatient follow-up showed favorable outcomes and near resolution. Conclusion: We reported a challenging case of worsening mpox after Tecovirimat treatment in the setting of new HIV and ART initiation concerning IRIS vs. Tecovirimat resistance. Clinicians should consider the risk of IRIS and weigh the pros and cons of initiating or delaying ART. In patients not responding to first-line treatment with tecovirimat, resistance testing should be performed, and alternative options should be considered. Future research is needed to establish guidance on the role of Cidofovir and Vaccinia immune globulin and the continuation of tecovirimat for refractory mpox.
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Affiliation(s)
- Andres E Martinez
- Division of Infectious Diseases, Department of Medicine, Jackson Memorial Hospital, Miami, FL 33136, USA
- Division of Infectious Diseases, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL 33146, USA
| | - Paola Frattaroli
- Division of Infectious Diseases, Department of Medicine, Jackson Memorial Hospital, Miami, FL 33136, USA
- Division of Infectious Diseases, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL 33146, USA
| | - Christine A Vu
- Department of Pharmacy, Jackson Memorial Hospital, Miami, FL 33136, USA
| | - Lizy Paniagua
- Division of Infectious Diseases, Department of Medicine, Jackson Memorial Hospital, Miami, FL 33136, USA
- Division of Infectious Diseases, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL 33146, USA
| | - Joel Mintz
- Department of Internal Medicine, University of Miami, Jackson Memorial Hospital, Miami, FL 33136, USA
| | | | - Paola Zamudio
- Universidad Anáhuac Querétaro, Querétaro 76246, Mexico
| | - Astrid Barco
- Universidad de Especialidades Espíritu Santo, Guayas 092301, Ecuador
| | - Aruna Rampersad
- Couva Hospital and Multi Training Facility, Couva 550214, Trinidad and Tobago
| | - Paola Lichtenberger
- Division of Infectious Diseases, Department of Medicine, Jackson Memorial Hospital, Miami, FL 33136, USA
- Division of Infectious Diseases, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL 33146, USA
| | - Jose A Gonzales-Zamora
- Division of Infectious Diseases, Department of Medicine, Jackson Memorial Hospital, Miami, FL 33136, USA
- Division of Infectious Diseases, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL 33146, USA
- Peruvian American Medical Society (PAMS), Albuquerque, NM 87111, USA
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Chen KH, Liu WD, Sun HY, Lin KY, Hsieh SM, Sheng WH, Chuang YC, Huang YS, Cheng A, Hung CC. Immune Reconstitution Inflammatory Syndrome in People Living with HIV Who Presented with Interstitial Pneumonitis: an Emerging Challenge in the Era of Rapid Initiation of Antiretroviral Therapy. Microbiol Spectr 2023; 11:e0498522. [PMID: 36877061 PMCID: PMC10100876 DOI: 10.1128/spectrum.04985-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/16/2023] [Indexed: 03/07/2023] Open
Abstract
Studies on immune reconstitution inflammatory syndrome (IRIS) in people living with HIV (PLWH) and presenting with interstitial pneumonitis (IP) are limited in the era of rapid antiretroviral therapy (ART) initiation, particularly with integrase strand-transfer inhibitor (INSTI)-containing regimens. Adult PLWH presenting with IP in whom ART was initiated within 30 days of IP diagnosis between 2015 and 2021 were retrospectively identified. The primary outcome was the occurrence of IRIS within 30 days after admission. Of 88 eligible PLWH with IP (median age, 36 years; CD4 count, 39 cells/mm3), Pneumocystis jirovecii and cytomegalovirus (CMV) DNA were detected via polymerase-chain-reaction assay in 69.3% and 91.7% of respiratory specimens, respectively. 22 PLWH (25.0%) had manifestations that met French's IRIS criteria for paradoxical IRIS. There were no statistically significant differences in terms of the all-cause mortality (0.0% versus 6.1%, P = 0.24), the occurrence of respiratory failure (22.7% versus 19.7%, P = 0.76), and pneumothorax (9.1% versus 7.6%, P = 0.82) between PLWH with and those without paradoxical IRIS. In a multivariable analysis, the factors associated with IRIS were the decline of the 1 month plasma HIV RNA load (PVL) with ART (adjusted hazard ratio [aHR] per 1 log decrease, 3.45; 95% CI, 1.52 to 7.81), a baseline CD4-to-CD8 ratio of <0.1 (aHR, 3.47; 95% CI, 1.16 to 10.44), and the rapid initiation of ART (aHR, 7.95; 95% CI, 1.04 to 60.90). In conclusion, we found a high rate of paradoxical IRIS among PLWH with IP in the era of rapid ART initiation with INSTI-containing ART and this was associated with immune depletion at baseline, a rapid decline of PVL, and an interval of <7 days between the diagnosis of IP and the initiation of ART. IMPORTANCE Our study of PLWH who presented with IP mainly due to Pneumocystis jirovecii demonstrates that a high rate of paradoxical IRIS and a rapid decline of PVL with the initiation of ART, a CD4-to-CD8 ratio of <0.1 at baseline, and a short interval (<7 days) between the diagnosis of IP and the initiation of ART were associated with paradoxical IP-IRIS in PLWH. Paradoxical IP-IRIS was not associated with mortality or respiratory failure with heightened awareness among the HIV-treating physicians, rigorous investigations to exclude the possibilities of concomitant infections, or the malignancies and adverse effects of medications, including the cautious use of corticosteroids.
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Affiliation(s)
- Kai-Hsiang Chen
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wang-Da Liu
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Medicine, National Taiwan University Cancer Center, Taipei, Taiwan
| | - Hsin-Yun Sun
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Kuan-Yin Lin
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- Center of Infection Control, National Taiwan University Hospital, Taipei, Taiwan
| | - Szu-Min Hsieh
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wang-Huei Sheng
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Medical Education, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- School of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yu-Chung Chuang
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yu-Shan Huang
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Aristine Cheng
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chien-Ching Hung
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin, Taiwan
- Department of Tropical Medicine and Parasitology, National Taiwan University College of Medicine, Taipei, Taiwan
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10
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Carrubba S, Geevarghese A, Solli E, Guttha S, Sims J, Sperber L, Meehan S, Ostrovsky A. Novel severe oculocutaneous manifestations of human monkeypox virus infection and their historical analogues. Lancet Infect Dis 2023; 23:e190-e197. [PMID: 36702137 PMCID: PMC9870321 DOI: 10.1016/s1473-3099(22)00869-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/05/2022] [Accepted: 12/12/2022] [Indexed: 01/25/2023]
Abstract
WHO has declared human mpox (formerly known as monkeypox) a global public health emergency since July, 2022. When case numbers were increasing, so did clinicians' exposures to new elements of the disease. Additionally, the burden of mpox is particularly apparent in immunocompromised patients, who can have more variable and severe manifestations of disease across organ systems. In this Grand Round, we report novel and severe oculocutaneous manifestations of mpox in this population, which are both sight and life threatening. Specifically, we highlight two patients with mpox and AIDS who had refractory skin necrosis that progressed to either ocular compromise or panfacial gangrene, or both. Both patients ultimately died due to systemic complications of their infections. Through clinical analogies, we show how past experiences with related orthopoxviruses, such as variola virus (smallpox) and vaccinia virus, can add useful context for understanding and treating these new disease states. We suspect that in patients who are immunocompromised, monkeypox virus can clinically evolve not only via viraemia but also through direct intradermal spread. We propose that intradermal spread occurs by a process clinically and immunologically analogous to progressive vaccinia, a complication previously seen after conventional smallpox vaccination. We share evidence in support of this theory and implications regarding early management and post-exposure prophylaxis for at-risk populations. Content note: this Grand Round contains graphic images of mpox lesions of the eyes and face.
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Affiliation(s)
- Steven Carrubba
- Department of Ophthalmology, NYU Langone Medical Center, New York, NY, USA
| | - Alexi Geevarghese
- Department of Ophthalmology, NYU Langone Medical Center, New York, NY, USA
| | - Elena Solli
- Department of Ophthalmology, NYU Langone Medical Center, New York, NY, USA
| | - Samyuktha Guttha
- Department of Ophthalmology, NYU Langone Medical Center, New York, NY, USA
| | - Jeffrey Sims
- Department of Ophthalmology, NYU Langone Medical Center, New York, NY, USA
| | - Laurence Sperber
- Department of Ophthalmology, NYU Langone Medical Center, New York, NY, USA
| | - Shane Meehan
- Department of Dermatology, NYU Langone Medical Center, New York, NY, USA
| | - Ann Ostrovsky
- Department of Ophthalmology, NYU Langone Medical Center, New York, NY, USA,Correspondence to: Dr Ann Ostrovsky, New York, NY 10017, USA
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11
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Moseki RM, Barber DL, Du Bruyn E, Shey M, Van der Plas H, Wilkinson RJ, Meintjes G, Riou C. Phenotypic Profile of Mycobacterium tuberculosis-Specific CD4 T-Cell Responses in People With Advanced Human Immunodeficiency Virus Who Develop Tuberculosis-Associated Immune Reconstitution Inflammatory Syndrome. Open Forum Infect Dis 2023; 10:ofac546. [PMID: 36726536 PMCID: PMC9879713 DOI: 10.1093/ofid/ofac546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 10/17/2022] [Indexed: 01/28/2023] Open
Abstract
Background Tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is a frequent complication of cotreatment for TB and human immunodeficiency virus (HIV)-1. We characterized Mycobacterium tuberculosis (Mtb)-specific CD4 T-cell phenotype and transcription factor profile associated with the development of TB-IRIS. Methods We examined the role of CD4 T-cell transcription factors in a murine model of mycobacterial IRIS. In humans, we used a longitudinal study design to compare the magnitude of antiretroviral therapy, activation, transcription factor profile, and cytotoxic potential of Mtb-specific CD4 T cells between TB-IRIS (n = 25) and appropriate non-IRIS control patients (n = 18) using flow cytometry. Results In the murine model, CD4 T-cell expression of Eomesodermin (Eomes), but not Tbet, was associated with experimentally induced IRIS. In patients, TB-IRIS onset was associated with the expansion of Mtb-specific IFNγ+CD4 T cells (P = .039). Patients with TB-IRIS had higher HLA-DR expression (P = .016), but no differences in the expression of T-bet or Eomes were observed. At TB-IRIS onset, Eomes+Tbet+Mtb-specific IFNγ+CD4+ T cells showed higher expression of granzyme B in patients with TB-IRIS (P = .026). Conclusions Although the murine model of Mycobacterium avium complex-IRIS suggests that Eomes+CD4 T cells underly IRIS, TB-IRIS was not associated with Eomes expression in patients. Mycobacterium tuberculosis-specific IFNγ+CD4 T-cell responses in TB-IRIS patients are differentiated, highly activated, and potentially cytotoxic.
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Affiliation(s)
- Raymond M Moseki
- Wellcome Center for Infectious Diseases Research in Africa (CIDRI-Africa), University of Cape Town, Cape Town, South Africa.,Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa
| | - Daniel L Barber
- T Lymphocyte Biology Section, Laboratory of Parasitic Diseases, National Institute of Health, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Elsa Du Bruyn
- Wellcome Center for Infectious Diseases Research in Africa (CIDRI-Africa), University of Cape Town, Cape Town, South Africa.,Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa
| | - Muki Shey
- Wellcome Center for Infectious Diseases Research in Africa (CIDRI-Africa), University of Cape Town, Cape Town, South Africa.,Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Helen Van der Plas
- Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa.,Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Robert J Wilkinson
- Wellcome Center for Infectious Diseases Research in Africa (CIDRI-Africa), University of Cape Town, Cape Town, South Africa.,Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa.,Department of Medicine, University of Cape Town, Cape Town, South Africa.,Department of Infectious Diseases, Imperial College London, London, United Kingdom.,The Francis Crick Institute, London, United Kingdom
| | - Graeme Meintjes
- Wellcome Center for Infectious Diseases Research in Africa (CIDRI-Africa), University of Cape Town, Cape Town, South Africa.,Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa.,Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Catherine Riou
- Wellcome Center for Infectious Diseases Research in Africa (CIDRI-Africa), University of Cape Town, Cape Town, South Africa.,Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa.,Department of Pathology, Division of Medical Virology, University of Cape Town, Cape Town, South Africa
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12
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de Sá NBR, de Souza NCS, Neira-Goulart M, Ribeiro-Alves M, Da Silva TP, Pilotto JH, Rolla VC, Giacoia-Gripp CBW, de Oliveira Pinto LM, Scott-Algara D, Morgado MG, Teixeira SLM. Inflammasome genetic variants are associated with tuberculosis, HIV-1 infection, and TB/HIV-immune reconstitution inflammatory syndrome outcomes. Front Cell Infect Microbiol 2022; 12:962059. [PMID: 36204643 PMCID: PMC9531132 DOI: 10.3389/fcimb.2022.962059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 08/30/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundTuberculosis (TB) and AIDS are the leading causes of infectious diseases death worldwide. Here, we investigated the relationship between from single nucleotide polymorphisms (SNPs) of the NLRP3, CARD8, AIM2, CASP-1, IFI16, and IL-1β inflammasome genes, as well as the profiles of secreted proinflammatory cytokines (e.g., IL-1β, IL-18, IL-33, and IL-6) with the TB clinical profiles, TB-HIV coinfection, and IRIS onset.MethodsThe individuals were divided into four groups: TB-HIV group (n=88; 11 of them with IRIS), HIV-1 group (n=20), TB group (n=24) and healthy volunteers (HC) group (n=10), and were followed up at INI/FIOCRUZ and HGNI (Rio de Janeiro/Brazil) from 2006 to 2016. Real-time PCR was used to determine the genotypes of the Single Nucleotide Polymorphism (SNPs), and ELISA was used to measure the plasma cytokine levels. Unconditional logistic regression models were used to perform risk estimations.ResultsA higher risk for extrapulmonary TB was associated with the TT genotype (aOR=6.76; P=0.026) in the NLRP3 rs4612666 Single Nucleotide Polymorphism (SNP) and the C-C-T-G-C haplotype (aOR=4.99; P= 0.017) in the NLRP3 variants. This same Single Nucleotide Polymorphism (SNP) was associated with lower risk against extrapulmonary TB when the carrier allele C (aOR=0.15; P=0.021) was present. Among those with HIV-1 infections, a higher risk for TB onset was associated with the GA genotype (aOR=5.5; P=0.044) in the IL1-β rs1143634 Single Nucleotide Polymorphism (SNP). In contrast, lower risk against TB onset was associated with the A-G haplotype (aOR=0.17; P= 0.026) in the CARD8 variants. Higher IL-6 and IL-33 levels were observed in individuals with TB. A higher risk for IRIS onset was associated with CD8 counts ≤ 500 cells/mm3 (aOR=12.32; P=0.010), the presence of extrapulmonary TB (aOR=6.6; P=0.038), and the CT genotype (aOR=61.06; P=0.026) or carrier allele T (aOR=61.06; P=0.026) in the AIM2 rs2276405 Single Nucleotide Polymorphism (SNP), whereas lower risk against IRIS onset was associated with the AT genotype (aOR=0.02; P=0.033) or carrier allele T (aOR=0.02; P=0.029) in the CARD8 rs2043211 Single Nucleotide Polymorphism (SNP) and the T-G haplotype (aOR=0.07; P= 0.033) in the CARD8 variants. No other significant associations were observed.ConclusionsOur results depict the involvement of genetic polymorphisms of crucial innate immunity genes and proinflammatory cytokines in the clinical outcomes related to TB-HIV coinfection.
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Affiliation(s)
- Nathalia Beatriz Ramos de Sá
- 1Laboratory of AIDS & Molecular Immunology, Oswaldo Cruz Institute, FIOCRUZ, Rio de Janeiro, Brazil
- *Correspondence: Mariza Gonçalves Morgado, ; Nathalia Beatriz Ramos de Sá,
| | | | - Milena Neira-Goulart
- 1Laboratory of AIDS & Molecular Immunology, Oswaldo Cruz Institute, FIOCRUZ, Rio de Janeiro, Brazil
| | - Marcelo Ribeiro-Alves
- Laboratory of Clinical Research on STD/AIDS, National Institute of Infectious Diseases Evandro Chagas, FIOCRUZ, Rio de Janeiro, Brazil
| | - Tatiana Pereira Da Silva
- 1Laboratory of AIDS & Molecular Immunology, Oswaldo Cruz Institute, FIOCRUZ, Rio de Janeiro, Brazil
| | - Jose Henrique Pilotto
- 1Laboratory of AIDS & Molecular Immunology, Oswaldo Cruz Institute, FIOCRUZ, Rio de Janeiro, Brazil
- Nova Iguaçu General Hospital, Nova Iguaçu, Rio de Janeiro, Brazil
| | - Valeria Cavalcanti Rolla
- Clinical Research Laboratory on Mycobacteria, National Institute of Infectious Diseases Evandro Chagas, FIOCRUZ, Rio de Janeiro, Brazil
| | | | | | - Daniel Scott-Algara
- Unité de Biologie Cellulaire des Lymphocytes, Institut Pasteur, Paris, France
| | - Mariza Gonçalves Morgado
- 1Laboratory of AIDS & Molecular Immunology, Oswaldo Cruz Institute, FIOCRUZ, Rio de Janeiro, Brazil
- *Correspondence: Mariza Gonçalves Morgado, ; Nathalia Beatriz Ramos de Sá,
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Lei JY, Chen H, Zhou DH, Xu LH, Fang JP, Mai YG. Pneumocystis jirovecii-associated immune reconstitution inflammatory syndrome-like phenomenon in a child with leukaemia: a case report and literature review. BMC Pediatr 2022; 22:410. [PMID: 35820900 PMCID: PMC9277966 DOI: 10.1186/s12887-022-03441-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 06/21/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Immune reconstitution inflammatory syndrome (IRIS) refers to the phenomenon of intense immune responses against pathogens in patients with AIDS undergoing antiretroviral therapy to reconstitute immune function, resulting in functional impairment of multiple organs. Non-AIDS immunosuppressed hosts may also develop similar manifestations to IRIS during immune recovery. CASE PRESENTATION An 8-year-old girl presented with acute lymphoblastic leukaemia was admitted for scheduled chemotherapy treatment. During chemotherapy, she experienced pancytopenia and Pneumocystis jirovecii pneumonia, which was diagnosed based on the abnormal shadows observed on chest computed tomography, the elevation of serum β-D-glucan, and the positive mNGS results of Pneumocystis jirovecii in both sputum and blood. After treatment with Granulocyte Colony-Stimulating Factor, sulfamethoxazole, and caspofungin, aggravation of lung lesions was discovered and severe interstitial lung disease developed in a short period along with a rapidly increasing leukocyte count. Intravenous methylprednisolone pulse therapy was given, but lung function did not improve, and she finally died after the withdrawal of medical care. CONCLUSIONS For patients with acute lymphocytic leukaemia infected with Pneumocystis jirovecii, the rapid aggravation of pulmonary lesions in the process of blood recovery and immune reconstitution should raise vigilance against the possibility of IRIS-like reactions. The use of granulocyte stimulating factors may aggravate the inflammatory response in the lungs. The timing, dosage, and duration of treatment of glucocorticoids and the impact of high-dose methylprednisolone pulse therapy on the prognosis of patients should be explored in further research.
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Affiliation(s)
- Jia-Ying Lei
- Key Laboratory of Malignant Tumor Gene Regulation and Target Therapy of Guangdong Higher Education Institutes, Sun Yat-Sen University, Guangzhou, People's Republic of China.,Children's Medical Center, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China
| | - Han Chen
- Key Laboratory of Malignant Tumor Gene Regulation and Target Therapy of Guangdong Higher Education Institutes, Sun Yat-Sen University, Guangzhou, People's Republic of China.,Children's Medical Center, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China
| | - Dun-Hua Zhou
- Key Laboratory of Malignant Tumor Gene Regulation and Target Therapy of Guangdong Higher Education Institutes, Sun Yat-Sen University, Guangzhou, People's Republic of China.,Children's Medical Center, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China
| | - Lu-Hong Xu
- Key Laboratory of Malignant Tumor Gene Regulation and Target Therapy of Guangdong Higher Education Institutes, Sun Yat-Sen University, Guangzhou, People's Republic of China.,Children's Medical Center, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China
| | - Jian-Pei Fang
- Key Laboratory of Malignant Tumor Gene Regulation and Target Therapy of Guangdong Higher Education Institutes, Sun Yat-Sen University, Guangzhou, People's Republic of China.,Children's Medical Center, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China
| | - You-Gang Mai
- Key Laboratory of Malignant Tumor Gene Regulation and Target Therapy of Guangdong Higher Education Institutes, Sun Yat-Sen University, Guangzhou, People's Republic of China. .,Children's Medical Center, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China.
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14
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Arora S, Ahmad FMH, Deshwal R, Behal P. Study of clinical profile and outcomes in progressive multifocal leukoencephalopathy in acquired immunodeficiency syndrome patients in the highly active antiretroviral therapy era - An observational study. Indian J Sex Transm Dis AIDS 2022; 43:156-160. [PMID: 36743095 PMCID: PMC9891026 DOI: 10.4103/ijstd.ijstd_29_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 03/03/2020] [Accepted: 10/27/2020] [Indexed: 11/17/2022] Open
Abstract
Background and Objectives Progressive multifocal leukoencephalopathy (PML) is a viral infection affecting the central nervous system (CNS) seen mostly in advanced human immunodeficiency virus (HIV) infection. There is limited data on the epidemiology and disease course of these patients from India. This study was aimed to determine the frequency of PML in patients with HIV/acquired immunodeficiency syndrome (AIDS) and the clinical presentation and prognosis of these patients. Materials and Methods The study was conducted at a tertiary care HIV center in New Delhi. Data of 765 patients from our anti-retroviral therapy (ART) clinic during a span of 4 years were retrospectively analyzed and reviewed. The diagnosis was based on the clinical and radiological picture and exclusion of other differential diagnosis by cerebrospinal fluid and serological studies. Results Of 765 patients with HIV/AIDS, 12 (1.56%) were diagnosed with PML on the basis of consistent clinical and radiological features after ruling out other differential diagnosis. PML was the initial presentation of HIV infection in 8 (55.5%) patients. 11 (89%) patients had CD4 count <200/μl. Insidious onset focal limb weakness (50%) and dysarthria (50%) were common symptoms. Magnetic resonance imaging of the brain revealed characteristic white matter lesions in all the patients. The estimated median survival was 40 months (95% confidence interval, 23.88-53.19 months). Interpretation and Conclusions Our results show that PML is associated with high morbidity despite the institution of highly active ART (HAART), but mortality has significantly declined if ART is started early. Key to good response is early diagnosis and HAART.
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Affiliation(s)
- Sumit Arora
- Assoc Prof Department of Medicine, Apex Immunodeficiency Centre, Base Hospital Delhi Cantt, Army College of Medical Sciences, Pataudi, Gurugram, Haryana, India
| | - Faiz M. H. Ahmad
- Prof Department of Medicine, Base Hospital Delhi Cantt, Army College of Medical Sciences, Pataudi, Gurugram, Haryana, India
| | - Rajesh Deshwal
- Consultant Physician, Shiv Ram Hospital, Pataudi, Gurugram, Haryana, India
| | - Pradeep Behal
- Assistant Prof Department of Medicine, Base Hospital Delhi Cantt, Army College of Medical Sciences, New Delhi, India
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15
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Zhao Y, Hohlfeld A, Namale P, Meintjes G, Maartens G, Engel ME. Risk of Immune Reconstitution Inflammatory Syndrome With Integrase Inhibitors Versus Other Classes of Antiretrovirals: A Systematic Review and Meta-analysis of Randomized Trials. J Acquir Immune Defic Syndr 2022; 90:232-239. [PMID: 35175970 PMCID: PMC7612870 DOI: 10.1097/qai.0000000000002937] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 02/02/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Integrase strand transfer inhibitors (InSTIs) decrease HIV plasma viral load faster than other antiretroviral classes. More rapid viral load decline has been associated with higher risk of immune reconstitution inflammatory syndrome (IRIS). There are conflicting reports on the association between InSTI and IRIS. We performed a systematic review and meta-analysis to compare the risk of IRIS among treatment-naive HIV-positive patients starting InSTI versus non-InSTI regimens. METHODS We searched PubMed, Scopus, Web of Science, Africa-Wide, and Cochrane databases from earliest available date to 26 November 2021, for randomized controlled trials (RCTs) having intervention arms with InSTI versus control arms without InSTI in patients initiating first-line antiretroviral therapy. The primary outcome was relative risk (RR) of IRIS, whereas the secondary outcome was RR of paradoxical tuberculosis-associated IRIS (TB-IRIS). Data were combined by random-effects meta-analysis according to the Mantel-Haenszel method. The protocol for this study is registered with PROSPERO, CRD42020213976. RESULTS We included 14 RCTs comprising 8696 participants from 6 continents for the primary outcome of IRIS and a subset of 674 participants (from 3 RCTs) for the secondary outcome of paradoxical TB-IRIS. Risk of IRIS was similar between InSTI and non-InSTI regimens (RR, 0.93; 95% confidence interval: 0.75 to 1.14). There was a trend towards a lower risk of paradoxical TB-IRIS with InSTI versus efavirenz regimens that was not statistically significant (RR, 0.64; 95% confidence interval: 0.34 to 1.19). CONCLUSIONS In this meta-analysis among treatment-naive patients commencing first-line antiretroviral therapy, InSTI regimens were not associated with higher risk of IRIS.
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Affiliation(s)
- Ying Zhao
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Ameer Hohlfeld
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| | - Phiona Namale
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Mark E Engel
- Department of Medicine, University of Cape Town, Cape Town, South Africa
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16
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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] [What about the content of this article? (0)] [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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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:cancers14040986. [PMID: 35205734 PMCID: PMC8869819 DOI: 10.3390/cancers14040986] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [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
- Correspondence: ; Tel.: +33-4-9174-4966 or +33-4-9174-6163; Fax: +33-4-9174-4962
| | - 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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18
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Chong YB, Lu PL, Ma YC, Yin HL, Chang CH. Epstein-Barr Virus-Associated Smooth Muscle Tumor and Its Correlation With CD4 Levels in a Patient With HIV Infection. Front Cell Infect Microbiol 2022; 12:725342. [PMID: 35141174 PMCID: PMC8818939 DOI: 10.3389/fcimb.2022.725342] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 01/03/2022] [Indexed: 11/28/2022] Open
Abstract
Epstein-Barr virus-associated smooth muscle tumor (EBV-SMT) is a rare tumor found in immunocompromised patients, and its treatment is not well-established. A role for antiretroviral therapy in human immunodeficiency virus (HIV)-related EBV-SMT has been proposed; however, the relevance of tumor size, CD4 levels, and immune reconstitution inflammatory syndrome (IRIS) has not been previously reported. We present the first case, to our knowledge, of a tumor that shrank in association with elevated CD4 counts. IRIS occurred in this case following antiretroviral therapy. This finding highlights the importance of the immune response in HIV-related EBV-SMT.
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Affiliation(s)
- Yoon Bin Chong
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Po-Liang Lu
- School of Medicine for Post-Baccalaureate, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of Infectious Disease, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center for Liquid Biopsy and Cohort Research, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yu-Chun Ma
- Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsin-Ling Yin
- Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chih-Hui Chang
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- *Correspondence: Chih-Hui Chang,
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19
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Abstract
Kaposi's sarcoma is an angioproliferative tumor caused by human herpesvirus 8 in the context of immunodeficiency, such as that induced by HIV infection or immunosuppressive therapy. Its incidence has dramatically fallen in patients living with HIV (PLHIV) since the introduction of potent antiretroviral combinations 25 years ago due to the restoration of immunity and better control of HIV replication. However, KS is still one of the most frequently occurring cancers in PLHIV, in particular in men who have sex with men and in sub-Saharan Africa, where it is still endemic. Even in the context of restored immunity, the risk of KS is still more than 30 times higher in PLHIV than in the general population. Recent evidence indicates that early initiation of antiretroviral treatment, which is recommended by current guidelines, may reduce the risk of KS but it needs to be accompanied by early access to care. This review mainly focuses on the recent epidemiological features of KS in the context of HIV infection.
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20
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Cuzin L, Delobel P, Martin-Blondel G. Letter to the editor. HIV Med 2021; 23:204-205. [PMID: 34747108 DOI: 10.1111/hiv.13192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 09/27/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Lise Cuzin
- University Hospital of Martinique, Infectious and Tropical Diseases Unit, Fort de France, France.,CERPOP, INSERM UMR1295, Toulouse University, Toulouse, France
| | - Pierre Delobel
- University Hospital of Toulouse, Infectious and Tropical Diseases Unit, Toulouse, France.,INSERM UMR1291-CNRS UMR5051, Toulouse University, Toulouse, France
| | - Guillaume Martin-Blondel
- University Hospital of Toulouse, Infectious and Tropical Diseases Unit, Toulouse, France.,INSERM UMR1291-CNRS UMR5051, Toulouse University, Toulouse, France
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21
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Ludgate S, Connolly SP, Fennell D, Muhamad MF, Welaratne I, Cotter A, McQuaid SE. Graves' disease associated with HIV disease and late immune reconstitution inflammatory syndrome following the initiation of antiretroviral therapy. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM210094. [PMID: 34612207 PMCID: PMC8558905 DOI: 10.1530/edm-21-0094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 09/14/2021] [Indexed: 11/08/2022] Open
Abstract
SUMMARY Both human immunodeficiency virus (HIV) and antiretroviral therapy (ART) are associated with endocrine dysfunction (1). The term 'immune reconstitution inflammatory syndrome' (IRIS) describes an array of inflammatory conditions that occur during the return of cell-mediated immunity following ART. Graves' disease (GD) occurs rarely as an IRIS following ART. In this study, we describe the case of a 40-year-old Brazilian female who was diagnosed with HIV following admission with cryptococcal meningitis and salmonellosis. At this time, she was also diagnosed with adrenal insufficiency. Her CD4 count at diagnosis was 17 cells/µL which rose to 256 cells/µL over the first 3 months of ART. Her HIV viral load, however, consistently remained detectable. When viral suppression was finally achieved 21 months post diagnosis, an incremental CD4 count of 407 cells/µL over the following 6 months ensued. Subsequently, she was diagnosed with a late IRIS to cryptococcus 32 months following initial ART treatment, which manifested as non-resolving lymphadenitis and resolved with high-dose steroids. Following the initiation of ART for 45 months, she developed symptomatic Graves' hyperthyroidism. At this time, her CD4 count had risen to 941 cells/µL. She has been rendered euthyroid on carbimazole. This case serves to remind us that GD can occur as an IRIS post ART and typically has a delayed presentation. LEARNING POINTS Endocrinologists should be aware of the endocrine manifestations of HIV disease, in particular, thyroid pathology. Endocrinologists should be aware that IRIS can occur following the initiation of ART. Thyroid dysfunction can occur post ART of which Graves' disease (GD) is the most common thyroid manifestation. GD as a manifestation of ART-induced IRIS can have a delayed presentation. Infectious disease physicians should be aware of endocrine manifestations associated with HIV and ART.
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Affiliation(s)
- S Ludgate
- Department of Diabetes and Endocrinology, Dublin, Ireland
| | - S P Connolly
- Department of Infectious Diseases, Dublin, Ireland
| | - D Fennell
- Department of Diabetes and Endocrinology, Dublin, Ireland
| | - M F Muhamad
- Department of Diabetes and Endocrinology, Dublin, Ireland
| | - I Welaratne
- Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - A Cotter
- Department of Infectious Diseases, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - S E McQuaid
- Department of Diabetes and Endocrinology, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
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22
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Caplan MR, Wilson EMP, Schechter M, Cai CW, Venner A, Bishop R, Adelsberger J, Higgins J, Roby G, Wang J, Sheikh V, Sereti I. High prevalence of gastrointestinal manifestations among Cytomegalovirus end-organ disease in the combination antiretroviral era. J Virus Erad 2021; 7:100052. [PMID: 34557308 PMCID: PMC8446803 DOI: 10.1016/j.jve.2021.100052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 09/07/2021] [Accepted: 09/07/2021] [Indexed: 11/30/2022] Open
Abstract
Background Cytomegalovirus (CMV) end-organ disease (EOD) continues to pose a significant risk to patients with advanced HIV disease despite decreased incidence with combination anti-retroviral therapy (ART) and lower mortality with effective anti-CMV therapy. Subclinical CMV shedding may also contribute to ongoing inflammation and non-infectious comorbidities. Methods We examined the occurrence of CMV EOD and CMV shedding in a cohort of patients participating in a prospective observational study of severely immunosuppressed (CD4 ≤100 cells/μl), ART-naïve, HIV-1 infected adult participants. Results We studied 206 participants, of whom 193 (93.7%) were CMV IgG positive. Twenty-five participants (12.1%) developed confirmed CMV EOD. At baseline, 47 (22.8%) had CMV viremia detectable by PCR in the absence of clinical disease (CMV viremia). The remaining 134 (65%) had neither CMV EOD nor CMV viremia detected at baseline. Five participants with CMV EOD (2.4% of total cohort, 20% of CMV EOD) met AIDS Clinical Trials Group criteria for CMV immune reconstitution inflammatory syndrome (IRIS). Only one-third of CMV EOD patients had retinitis, while two-thirds presented with histologically confirmed gastrointestinal illness. CMV viremia was associated with higher percentages of activated CD8+ T cells even after HIV suppression. Conclusion The manifestations of CMV EOD in advanced HIV disease before and after initiation of ART may be more diverse than previously described, with high incidence of gastrointestinal illness. Recognition and treatment of unusual clinical presentations of CMV infection remains important in reducing morbidity and mortality from HIV co-infections. Cytomegalovirus end organ disease (CMV EOD) remains an important complication in HIV/AIDS patients. We found that gastrointestinal disease was the most common presentation of CMV EOD. In addition, subclinical CMV viremia was associated with increased immune activation.
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Affiliation(s)
- Margaret R Caplan
- Clinical Research Directorate, Frederick National Laboratory for Cancer Research, Bethesda, MD, 20817, USA
| | - Eleanor M P Wilson
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Melissa Schechter
- Clinical Research Directorate, Frederick National Laboratory for Cancer Research, Bethesda, MD, 20817, USA.,Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Catherine W Cai
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Allison Venner
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Rachel Bishop
- National Eye Institute, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Joseph Adelsberger
- Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, MD, 21701, USA
| | - Jeanette Higgins
- Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, MD, 21701, USA
| | - Gregg Roby
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Jing Wang
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD, 21701, USA
| | - Virginia Sheikh
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Irini Sereti
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, 20892, USA
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23
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Traversat P, Lauzeral A, Michalak S, Mahieu R, Berteau F, Dubée V. Exacerbation of acrodermatitis chronica atrophicans under antiretroviral treatment in an HIV-infected patient. J Eur Acad Dermatol Venereol 2021; 36:e107-e109. [PMID: 34487606 DOI: 10.1111/jdv.17647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/26/2021] [Indexed: 11/27/2022]
Affiliation(s)
- P Traversat
- Infectious and Tropical Diseases Department, Angers University Hospital, Angers, France
| | - A Lauzeral
- Infectious and Tropical Diseases Department, Angers University Hospital, Angers, France
| | - S Michalak
- Pathology lab, Angers University Hospital, Angers, France
| | - R Mahieu
- Infectious and Tropical Diseases Department, Angers University Hospital, Angers, France
| | - F Berteau
- Infectious and Tropical Diseases Department, Angers University Hospital, Angers, France
| | - V Dubée
- Infectious and Tropical Diseases Department, Angers University Hospital, Angers, France.,CRCINA, Inserm, Université de Nantes, Université d'Angers, Angers, France
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24
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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25
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Kann G, Wetzstein N, Bielke H, Schuettfort G, Haberl AE, Wolf T, Kuepper-Tetzel CP, Wieters I, Kessel J, de Leuw P, Bickel M, Khaykin P, Stephan C. Risk factors for IRIS in HIV-associated Pneumocystis-pneumonia following ART initiation. J Infect 2021; 83:347-353. [PMID: 34242683 DOI: 10.1016/j.jinf.2021.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/27/2021] [Accepted: 06/30/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND HIV-infected patients with Pneumocystis-pneumonia (PCP) may develop paradoxical immune reconstitution inflammatory syndrome (IRIS), when combination antiretroviral therapy (cART) is started early during the course of PCP-treatment (PCPT). The aim of this study was to identify risk factors and predictors for PCP-IRIS and to improve individualized patient care. METHODS An ICD-10 code hospital database query identified all Frankfurt HIV Cohort patients being diagnosed with PCP from January 2010 - June 2016. Patient charts were evaluated retrospectively for demographic, clinical and therapeutic (cART/PCPT) characteristics and incidence of paradoxical IRIS according to French's case definitions. RESULTS IRIS occurred in 12/97 patients that started cART while on PCPT (12.4%). They had a higher rate of re-hospitalization (41.7vs. 4.7%; odds ratio (OR) 14.46; p = 0.009), intensive care treatment (66.7vs. 30.6%; OR = 4.54; p = 0.018), and longer median hospitalization (48 days vs. 23; p < 0.001). A high HIV-RNA level (> 6Log10/ml) before cART initiation was associated with IRIS development (41.6vs. 15.0%; OR 4.05; p = 0.042). Serum immunoglobulin G-levels (IgG) [mg/dl] were lower (894.0 vs. 1446.5; p = 0.023). CONCLUSION Higher hospitalization rate and morbidity parameters underscore the clinical importance of PCP-related paradoxical IRIS. A baseline viral load of > 6Log10/ml and serum IgG may help to assess individual risks for PCP-IRIS.
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Affiliation(s)
- Gerrit Kann
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, Frankfurt am Main 60590, Germany
| | - Nils Wetzstein
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, Frankfurt am Main 60590, Germany
| | - Hannah Bielke
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, Frankfurt am Main 60590, Germany
| | - Gundolf Schuettfort
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, Frankfurt am Main 60590, Germany
| | - Annette E Haberl
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, Frankfurt am Main 60590, Germany
| | - Timo Wolf
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, Frankfurt am Main 60590, Germany
| | - Claus P Kuepper-Tetzel
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, Frankfurt am Main 60590, Germany
| | - Imke Wieters
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, Frankfurt am Main 60590, Germany
| | | | | | | | | | - Christoph Stephan
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, Frankfurt am Main 60590, Germany.
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26
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Kim J, Nam HJ, Kang SJ, Jung SI, Hwang CH, Kim YS, Chang HH, Kim SW, Park KH. Integrase strand transfer inhibitor treatment does not increase the incidence of immune reconstitution inflammatory syndrome in HIV-infected Koreans. HIV Med 2021; 22:705-714. [PMID: 34046975 DOI: 10.1111/hiv.13117] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Immune reconstitution inflammatory syndrome (IRIS) is a major concern when starting antiretroviral therapy (ART) in patients with advanced HIV infection. The aim of this study was to determine the incidence and risk factors of IRIS in HIV-infected Koreans initiating ART, and whether integrase strand transfer inhibitor (INSTI) treatment increases the risk of IRIS. METHODS This retrospective analysis included adults living with HIV, seen at four university-affiliated hospitals in South Korea, who were naïve to ART and had a CD4 T-cell count < 200 cells/μL between January 2004 and May 2019. IRIS was determined through a medical record review within 6 months of ART initiation. Propensity score-matched case-control study between the non-INSTI and INSTI groups was performed. RESULTS The study included 501 patients; 192 were assigned to the INSTI group, who started ART based on INSTIs as the initial treatment. There were opportunistic infections (OIs) in 253 (50.5%) cases before ART initiation. The three most common OIs were Pneumocystis jirovecii pneumonia, candidiasis and tuberculosis (TB). We identified 47 cases of IRIS; TB-IRIS was the most common type. The incidence of IRIS within 6 months of ART initiation was 9.4%, and there were no significant differences in baseline characteristics and incidence of IRIS between the matched groups. The risk factors for IRIS were pre-ART CD4 T-cell count (< 30 cells/μL), higher pre-ART viral load (≥ 75 000 copies/mL), and TB-OI. CONCLUSIONS The incidence of IRIS was 9.4% in Korean HIV patients. The INSTI regimen was not related to IRIS occurrence.
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Affiliation(s)
- J Kim
- Department of Infectious Diseases, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - H-J Nam
- Department of Infectious Diseases, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - S-J Kang
- Department of Infectious Diseases, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - S-I Jung
- Department of Infectious Diseases, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - C H Hwang
- Biomedical Research Institute, Chonnam National University Hospital, Gwangju, Korea
| | - Y-S Kim
- Department of Internal Medicine, Chungnam National University Medical School, Deajeon, Korea
| | - H-H Chang
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - S-W Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - K-Hwa Park
- Department of Infectious Diseases, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
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Pett SL, Spyer M, Haddow LJ, Nhema R, Benjamin LA, Najjuka G, Bilima S, Daud I, Musoro G, Kitabalwa J, Selemani G, Kandie S, Cornelius KM, Katemba C, Berkley JA, Hassan AS, Kityo C, Hakim J, Heyderman RS, Gibb DM, Walker AS. Benefits of enhanced infection prophylaxis at antiretroviral therapy initiation by cryptococcal antigen status. AIDS 2021; 35:585-594. [PMID: 33306556 PMCID: PMC7613319 DOI: 10.1097/qad.0000000000002781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To assess baseline prevalence of cryptococcal antigen (CrAg) positivity; and its contribution to reductions in all-cause mortality, deaths from cryptococcus and unknown causes, and new cryptococcal disease in the REALITY trial. DESIGN Retrospective CrAg testing of baseline and week-4 plasma samples in all 1805 African adults/children with CD4+ cell count less than 100 cells/μl starting antiretroviral therapy who were randomized to receive 12-week enhanced-prophylaxis (fluconazole 100 mg/day, azithromycin, isoniazid, cotrimoxazole) vs. standard-prophylaxis (cotrimoxazole). METHODS Proportional hazards models were used to estimate the relative impact of enhanced-prophylaxis vs. standard-cotrimoxazole on all, cryptococcal and unknown deaths, and new cryptococcal disease, through 24 weeks, by baseline CrAg positivity. RESULTS Excluding 24 (1.4%) participants with active/prior cryptococcal disease at enrolment (all treated for cryptococcal disease), 133/1781 (7.5%) participants were CrAg-positive. By 24 weeks, 105 standard-cotrimoxazole vs. 78 enhanced-prophylaxis participants died. Of nine standard-cotrimoxazole and three enhanced-prophylaxis cryptococcal deaths, seven and two, respectively, were CrAg-positive at baseline. Among deaths of unknown cause, only 1/46 standard-cotrimoxazole and 1/28 enhanced-prophylaxis were CrAg-positive at baseline. There was no evidence that relative reductions in new cryptococcal disease associated with enhanced-prophylaxis varied between baseline CrAg-positives [hazard-ratio = 0.36 (95% confidence interval 0.13-0.98), incidence 19.5 vs. 56.5/100 person-years] and CrAg-negatives [hazard-ratio = 0.33 (0.03-3.14), incidence 0.3 vs. 0.9/100 person-years; Pheterogeneity = 0.95]; nor for all deaths, cryptococcal deaths or unknown deaths (Pheterogeneity > 0.3). CONCLUSION Relative reductions in cryptococcal disease/death did not depend on CrAg status. Deaths of unknown cause were unlikely to be cryptococcus-related; plausibly azithromycin contributed to their reduction. Findings support including 100 mg fluconazole in an enhanced-prophylaxis package at antiretroviral therapy initiation where CrAg screening is unavailable/impractical.
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Affiliation(s)
- Sarah L. Pett
- Institute for Global Health
- MRC CTU at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
- Kirby Institute for Infection and Immunity in Society, University of New South Wales, Sydney, New South Wales, Australia
| | - Moira Spyer
- MRC CTU at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | | | - Ruth Nhema
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | - Laura A. Benjamin
- Institute of Neurology, UCL, London
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | | | - Sithembile Bilima
- Department/College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Godfrey Musoro
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | | | - George Selemani
- Department/College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | | | | | | | | | - Cissy Kityo
- Joint Clinical Research Centre, Kampala, Uganda
| | - James Hakim
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | - Robert S. Heyderman
- Department/College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Division of Infection and Immunity, UCL, London, UK
| | - Diana M. Gibb
- MRC CTU at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Ann S. Walker
- MRC CTU at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
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28
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Melzani A, de Reynal de Saint Michel R, Ntab B, Djossou F, Epelboin L, Nacher M, Blanchet D, Demar M, Couppie P, Adenis A. Incidence and Trends in Immune Reconstitution Inflammatory Syndrome Associated With Histoplasma capsulatum Among People Living With Human Immunodeficiency Virus: A 20-Year Case Series and Literature Review. Clin Infect Dis 2021; 70:643-652. [PMID: 30921453 DOI: 10.1093/cid/ciz247] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 03/21/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Histoplasmosis is among the main acquired immunodeficiency syndrome (AIDS)-defining conditions in endemic areas. Although histoplasmosis has a worldwide distribution, histoplasmosis-associated immune reconstitution inflammatory syndrome (IRIS) in people living with human immunodeficiency virus (PLHIV) is rarely reported.This study aimed to describe the incidence and features of histoplasmosis-associated IRIS in a cohort of PLHIV. METHODS A retrospective multicenter study was conducted in French Guiana from 1 January 1997 to 30 September 2017. The target population was represented by PLHIV who presented an episode of histoplasmosis within 6 months after antiretroviral therapy initiation. We used a consensual IRIS case definition, submitted to the agreement of 2 experts. Each case was described using a standardized questionnaire, and all patients gave informed consent. RESULTS Twenty-two cases of histoplasmosis-associated IRIS were included (14 infectious/unmasking and 8 paradoxical), with an overall incidence rate of 0.74 cases per 1000 HIV-infected person-years (95% confidence interval, 0.43-1.05). Mean age was 40.5 years. The ratio of males to females was 1:4. Median time to IRIS was 11 days (interquartile range 7-40 days) after antiretroviral therapy initiation. The main clinical presentation was fever, without any specific pattern, and disseminated disease. We reported 2 severe cases and partial or complete recovery at 1 month was the rule. Twenty-two cases were identified in the literature with similar characteristics. CONCLUSIONS Histoplasmosis-associated IRIS incidence was low but generated significant morbidity in PLHIV. In endemic areas, screening for latent or subclinical histoplasmosis should be implemented before antiretroviral therapy initiation.
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Affiliation(s)
- Alessia Melzani
- Unité de Maladies Infectieuses et Tropicales, Centre Hospitalier de Cayenne.,Equipe EA3593, Ecosystèmes Amazoniens et Pathologie Tropicale, Université de Guyane, Cayenne
| | | | - Balthazar Ntab
- Département d'Information Médicale, Centre Hospitalier de l'Ouest Guyanais, Saint Laurent du Maroni
| | - Felix Djossou
- Unité de Maladies Infectieuses et Tropicales, Centre Hospitalier de Cayenne.,Equipe EA3593, Ecosystèmes Amazoniens et Pathologie Tropicale, Université de Guyane, Cayenne
| | - Loic Epelboin
- Unité de Maladies Infectieuses et Tropicales, Centre Hospitalier de Cayenne.,Equipe EA3593, Ecosystèmes Amazoniens et Pathologie Tropicale, Université de Guyane, Cayenne
| | - Mathieu Nacher
- Equipe EA3593, Ecosystèmes Amazoniens et Pathologie Tropicale, Université de Guyane, Cayenne.,Centre d'Investigation Clinique Antilles Guyane, Inserm CIC 1424, Centre Hospitalier de Cayenne
| | - Denis Blanchet
- Equipe EA3593, Ecosystèmes Amazoniens et Pathologie Tropicale, Université de Guyane, Cayenne.,Laboratoire Hospitalo-Universitaire de Parasitologie-Mycologie, Centre Hospitalier de Cayenne, France
| | - Magalie Demar
- Equipe EA3593, Ecosystèmes Amazoniens et Pathologie Tropicale, Université de Guyane, Cayenne.,Laboratoire Hospitalo-Universitaire de Parasitologie-Mycologie, Centre Hospitalier de Cayenne, France
| | - Pierre Couppie
- Equipe EA3593, Ecosystèmes Amazoniens et Pathologie Tropicale, Université de Guyane, Cayenne.,Service de Dermatologie-Vénérologie, Centre Hospitalier de Cayenne
| | - Antoine Adenis
- Equipe EA3593, Ecosystèmes Amazoniens et Pathologie Tropicale, Université de Guyane, Cayenne.,Centre d'Investigation Clinique Antilles Guyane, Inserm CIC 1424, Centre Hospitalier de Cayenne
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Auld SC, Maenetje P, Ravimohan S, Weissman D, Ncube I, Mlotshwa M, Ratsela N, Chase W, Vangu MDT, Wallis R, Churchyard G, Kornfeld H, Bisson GP. Declines in Lung Function After Antiretroviral Therapy Initiation in Adults With Human Immunodeficiency Virus and Tuberculosis: A Potential Manifestation of Respiratory Immune Reconstitution Inflammatory Syndrome. Clin Infect Dis 2021; 70:1750-1753. [PMID: 31552412 PMCID: PMC7146005 DOI: 10.1093/cid/ciz733] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 08/27/2019] [Indexed: 12/20/2022] Open
Abstract
End-organ impairment has received relatively little research attention as a possible manifestation of tuberculosis immune reconstitution inflammatory syndrome (TB-IRIS). In this prospective cohort study, one-half of adults with human immunodeficiency virus and pulmonary tuberculosis experienced meaningful declines in lung function on antiretroviral therapy, suggesting a role for lung function in TB-IRIS definitions.
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Affiliation(s)
- Sara C Auld
- School of Medicine and Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Shruthi Ravimohan
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Drew Weissman
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Itai Ncube
- Aurum Institute, Johannesburg, South Africa
| | | | | | - William Chase
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Mboyo-Di-Tamba Vangu
- Nuclear Medicine, CM Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Gavin Churchyard
- Aurum Institute, Johannesburg, South Africa.,Advancing Care and Treatment for TB/HIV, a Collaborating Centre of the South African Medical Research Council, Johannesburg, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Hardy Kornfeld
- Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Gregory P Bisson
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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30
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Wang Y, Zhao N, Yang J, Wen Y. Case Report: Orbital Myositis and Myasthenia Gravis as Symptoms of Immune Reconstitution Inflammatory Syndrome in a Patient With Human Immunodeficiency Virus Infection. Front Immunol 2020; 11:595068. [PMID: 33381117 PMCID: PMC7768007 DOI: 10.3389/fimmu.2020.595068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 11/05/2020] [Indexed: 12/15/2022] Open
Abstract
We present a case of a 37-year-old man with HIV infection who had been on antiretroviral therapy for one year. He was admitted to our hospital with red and swollen eyes, acute onset progressive exophthalmos, and intermittent diplopia endured for 7 days. His symptoms, exam, and imaging led to a diagnosis of immune reconstitution inflammatory syndrome associated orbital myositis. His symptoms improved considerably after glucocorticoid therapy. Following a reduction in the oral prednisone dose, he re-presented with left ptosis, which rapidly progressed to bilateral ptosis. Diagnostic testing led to the diagnosis of immune mediated myasthenia gravis. Treatment with pyridostigmine bromide, prednisone, and tacrolimus was initiated. One month later, the patient's symptoms improved significantly. There was a probable association between his symptoms and autoimmune immune reconstitution inflammatory syndrome. This report highlights the importance of recognizing autoimmune disorders in human immunodeficiency virus-infected patients undergoing antiretroviral therapy. Orbital myositis and myasthenia gravis in human immunodeficiency virus-infected patients correlate closely with immunity status following a marked increase in CD4+ T cell counts.
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Affiliation(s)
- Yanli Wang
- Infectious Diseases Department, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Ning Zhao
- Department of Ophthalmology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Jun Yang
- Neurology Department, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Ying Wen
- Infectious Diseases Department, The First Affiliated Hospital of China Medical University, Shenyang, China
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31
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Nakamura H, Tateyama M, Tasato D, Haranaga S, Higa F, Matsuzaki A, Yoshimi N, Fujita J. Human immunodeficiency virus-associated pulmonary sarcoidosis in a Japanese man as a manifestation of immune reconstitution inflammatory syndrome. Clin Case Rep 2020; 8:3440-3444. [PMID: 33363948 PMCID: PMC7752423 DOI: 10.1002/ccr3.3438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/16/2020] [Accepted: 09/28/2020] [Indexed: 11/22/2022] Open
Abstract
Asymptomatic pulmonary sarcoidosis can develop after starting antiretroviral therapy. The decision on whether to treat sarcoidosis with corticosteroids should be based on the disease severity.
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Affiliation(s)
- Hideta Nakamura
- Department of Infectious, Respiratory, and Digestive MedicineUniversity of the Ryukyus Graduate of School of MedicineNishiharaJapan
| | - Masao Tateyama
- Department of Infectious, Respiratory, and Digestive MedicineUniversity of the Ryukyus Graduate of School of MedicineNishiharaJapan
| | - Daisuke Tasato
- Department of Respiratory MedicineHokubu Chiku Ishikai HospitalNagoJapan
| | - Shusaku Haranaga
- Department of Infectious, Respiratory, and Digestive MedicineUniversity of the Ryukyus Graduate of School of MedicineNishiharaJapan
| | - Futoshi Higa
- Department of Respiratory MedicineNational Hospital Organization Okinawa National HospitalGinowanJapan
| | | | - Naoki Yoshimi
- Department of PathologyOkinawa Red Cross HospitalNahaJapan
| | - Jiro Fujita
- Department of Infectious, Respiratory, and Digestive MedicineUniversity of the Ryukyus Graduate of School of MedicineNishiharaJapan
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32
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Poester VR, Munhoz LS, Basso RP, Roca BM, Vieira MU, Melo AM, Klafke GB, Sanchotene KO, Silveira JM, Stevens D, Rabello VBDS, Zancope-Oliveira RM, Xavier MO. Disseminated sporotrichosis with immune reconstitution inflammatory syndrome in an HIV patient: Case report and review of the literature. Rev Iberoam Micol 2020; 37:97-99. [PMID: 33168342 DOI: 10.1016/j.riam.2020.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 08/13/2020] [Accepted: 09/14/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Sporotrichosis has been occurring as outbreaks in Brazil, reaching epidemic levels in some regions. Zoonotic transmission is the main route to acquire Sporothrix. CASE REPORT We describe a case of disseminated sporotrichosis caused by Sporothrix brasiliensis in an HIV/AIDS patient, with the presentation of immune reconstitution inflammatory syndrome (IRIS). CONCLUSIONS This case reinforces that sporotrichosis should always be suspected in patients with IRIS from endemic regions, even in patients without the typical cutaneous lesions of this mycosis.
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Affiliation(s)
- Vanice Rodrigues Poester
- Programa de Pós Graduação em Ciências da Saúde, Faculdade de Medicina (FAMED), Universidade Federal do Rio Grande (FURG), RS, Brazil
| | - Lívia Silveira Munhoz
- Programa de Pós Graduação em Ciências da Saúde, Faculdade de Medicina (FAMED), Universidade Federal do Rio Grande (FURG), RS, Brazil
| | - Rossana Patricia Basso
- Programa de Pós Graduação em Ciências da Saúde, Faculdade de Medicina (FAMED), Universidade Federal do Rio Grande (FURG), RS, Brazil; FAMED-FURG, Brazil
| | | | | | - Aryse Martins Melo
- Programa de Pós-Graduação em Parasitologia, Universidade Federal de Pelotas (UFPel), Brazil
| | | | | | | | - David Stevens
- California Institute for Medical Research, San Jose, California, and Div. of Infectious Diseases and Geographic Medicine, Stanford University Medical School, Stanford, CA, USA
| | - Vanessa Brito de Souza Rabello
- Laboratório de Micologia, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brazil
| | - Rosely Maria Zancope-Oliveira
- Laboratório de Micologia, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brazil
| | - Melissa Orzechowski Xavier
- Programa de Pós Graduação em Ciências da Saúde, Faculdade de Medicina (FAMED), Universidade Federal do Rio Grande (FURG), RS, Brazil; FAMED-FURG, Brazil; Programa de Pós-Graduação em Parasitologia, Universidade Federal de Pelotas (UFPel), Brazil; California Institute for Medical Research, San Jose, California, and Div. of Infectious Diseases and Geographic Medicine, Stanford University Medical School, Stanford, CA, USA.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Piñeirua-Menéndez A, Flores-Miranda R, Sánchez-Nava D, Ortega-Pérez R, Belaunzaran-Zamudio PF, Pérez-Patrigeon S, Cárdenas-Ochoa A, Oseguera-Moguel J, Galindo-Uribe J, Orihuela-Sandoval C, Vázquez-Ortiz Z, Vázquez-Lamadrid J, Morelos-Guzmán M, Rosales-Uvera S, Crabtree-Ramírez B, Sierra-Madero J. Myocardial Inflammatory Changes Before and After Antiretroviral Therapy Initiation in People With Advanced Human Immunodeficiency Virus Disease. Open Forum Infect Dis 2020; 7:ofaa297. [PMID: 32818141 PMCID: PMC7423298 DOI: 10.1093/ofid/ofaa297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 07/24/2020] [Indexed: 11/12/2022] Open
Abstract
Because of the high frequency of late presentation of human immunodeficiency virus (HIV) disease in our population, we decided to explore the presence of myocarditis among people with HIV infection and advanced immunosuppression (less than 200 CD4+ cells/μL) and to describe the inflammatory changes observed after combined antiretroviral therapy initiation in an observational, longitudinal, prospective cohort. We performed both cardiovascular magnetic resonance imaging and doppler transthoracic echocardiogram.
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Affiliation(s)
- A Piñeirua-Menéndez
- Centro Nacional para la Prevención y Control del VIH y del SIDA, Ciudad de México
| | - R Flores-Miranda
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Departamento de Medicina Interna, Ciudad de México
| | - D Sánchez-Nava
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Departamento de Imagenología, Ciudad de México
| | - R Ortega-Pérez
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Departamento de Medicina Interna, Ciudad de México
| | - P F Belaunzaran-Zamudio
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Departamento de Infectología, Ciudad de México
| | - S Pérez-Patrigeon
- Division of Infectious Diseases, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - A Cárdenas-Ochoa
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Departamento de Infectología, Ciudad de México
| | - J Oseguera-Moguel
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Departamento de Cardiología, Ciudad de México
| | - J Galindo-Uribe
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Departamento de Cardiología, Ciudad de México
| | - C Orihuela-Sandoval
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Departamento de Cardiología, Ciudad de México
| | - Z Vázquez-Ortiz
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Departamento de Cardiología, Ciudad de México
| | - Jorge Vázquez-Lamadrid
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Departamento de Imagenología, Ciudad de México
| | - M Morelos-Guzmán
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Departamento de Imagenología, Ciudad de México
| | - S Rosales-Uvera
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Departamento de Imagenología, Ciudad de México
| | - B Crabtree-Ramírez
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Departamento de Infectología, Ciudad de México
| | - J Sierra-Madero
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Departamento de Infectología, Ciudad de México
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Navis A, Siddiqi O, Chishimba L, Zimba S, Morgello S, Birbeck GL. Immune reconstitution inflammatory syndrome in the central nervous system: Limitations for diagnosis in resource limited settings. J Neurol Sci 2020; 416:117042. [PMID: 32712429 DOI: 10.1016/j.jns.2020.117042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 07/10/2020] [Accepted: 07/13/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The diagnosis of IRIS is based on evidence of clinical worsening and immune reconstitution in the setting of combined antiretroviral therapy (cART) initiation. While central nervous system IRIS (CNS IRIS) is thought to be prevalent in resource limited settings (RLS), its identification is constrained by limited data on pre-treatment HIV disease and diagnostic testing. A diagnosis can be improved with neuroimaging and cerebrospinal fluid (CSF) studies, which are not universally available in RLS. This study evaluated whether diagnoses of CNS IRIS could be achieved in a resource limited setting based on established criteria. METHODS A retrospective chart review of HIV+ individuals, on ARVs at the time of presentation in two cohort studies of suspected CNS opportunistic infection or tuberculous (TB) meningitis who were admitted to a tertiary care facility in Lusaka, Zambia. RESULTS Using currently validated criteria, none of the 254 participants evaluated could be diagnosed with CNS IRIS, as there was no information on post-treatment trajectory of HIV viral loads or CD4 counts. Only one participant had a definitive, non-IRIS infectious diagnosis based on comprehensive testing. Of the remaining 253 patients, 68 (27%) had an identified potential CNS pathogen, 92 (36%) had inflammatory CSF in the absence of a pathogen, and 94 (37%) had normal CSF despite presenting with CNS symptoms. CONCLUSION The absence of HIV disease trajectory data, and lack of comprehensive diagnostic testing, compounded by a high prevalence of infectious pathogens, substantially limits the ability to diagnose CNS IRIS in RLS.
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Affiliation(s)
- Allison Navis
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.
| | - Omar Siddiqi
- Department of Internal Medicine, University of Zambia School of Medicine, Lusaka, Zambia; Global Neurology Program, Division of Neuroimmunology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States of America; Center for Virology and Vaccine Research, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States of America
| | - Lorraine Chishimba
- Department of Neurology, University Teaching Hospital, University of Zambia, Zambia
| | - Stanley Zimba
- Department of Neurology, University Teaching Hospital, University of Zambia, Zambia
| | - Susan Morgello
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America; Departments of Neuroscience and Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Gretchen L Birbeck
- University of Zambia School of Medicine, Lusaka, Zambia; University of Rochester School of Medicine, Rochester, NY, United States of America
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Harypursat V, Zhou Y, Tang S, Chen Y. JC Polyomavirus, progressive multifocal leukoencephalopathy and immune reconstitution inflammatory syndrome: a review. AIDS Res Ther 2020; 17:37. [PMID: 32631361 PMCID: PMC7338111 DOI: 10.1186/s12981-020-00293-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 06/29/2020] [Indexed: 01/15/2023] Open
Abstract
The human neurotropic virus JC Polyomavirus, a member of the Polyomaviridae family, is the opportunistic infectious agent causing progressive multifocal leukoencephalopathy, typically in immunocompromised individuals. The spectrum of underlying reasons for the systemic immunosuppression that permits JCV infection in the central nervous system has evolved over the past 2 decades, and therapeutic immunosuppression arousing JCV infection in the brain has become increasingly prominent as a trigger for PML. Effective immune restoration subsequent to human immunodeficiency virus-related suppression is now recognized as a cause for unexpected deterioration of symptoms in patients with PML, secondary to a rebound inflammatory phenomenon called immune reconstitution inflammatory syndrome, resulting in significantly increased morbidity and mortality in a disease already infamous for its lethality. This review addresses current knowledge regarding JC Polyomavirus, progressive multifocal leukoencephalopathy, progressive multifocal leukoencephalopathy-related immune reconstitution inflammatory syndrome, and the immunocompromised states that incite JC Polyomavirus central nervous system infection, and discusses prospects for the future management of these conditions.
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Affiliation(s)
- Vijay Harypursat
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Geleshan Town, Shapingba District, Chongqing, 400036, People's Republic of China
| | - Yihong Zhou
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Geleshan Town, Shapingba District, Chongqing, 400036, People's Republic of China
| | - Shengquan Tang
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Geleshan Town, Shapingba District, Chongqing, 400036, People's Republic of China
| | - Yaokai Chen
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Geleshan Town, Shapingba District, Chongqing, 400036, People's Republic of China.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Kintu K, Malaba TR, Nakibuka J, Papamichael C, Colbers A, Byrne K, Seden K, Hodel EM, Chen T, Twimukye A, Byamugisha J, Reynolds H, Watson V, Burger D, Wang D, Waitt C, Taegtmeyer M, Orrell C, Lamorde M, Myer L, Khoo S. Dolutegravir versus efavirenz in women starting HIV therapy in late pregnancy (DolPHIN-2): an open-label, randomised controlled trial. Lancet HIV 2020; 7:e332-e339. [PMID: 32386721 PMCID: PMC10877544 DOI: 10.1016/s2352-3018(20)30050-3] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 02/10/2020] [Accepted: 02/11/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Late initiation of HIV antiretroviral therapy (ART) in pregnancy is associated with not achieving viral suppression before giving birth and increased mother-to-child transmission of HIV. We aimed to investigate virological suppression before giving birth with dolutegravir compared with efavirenz, when initiated during the third trimester. METHODS In this randomised, open-label trial, DolPHIN-2, we recruited pregnant women in South Africa and Uganda aged at least 18 years, with untreated but confirmed HIV infection and an estimated gestation of at least 28 weeks, initiating ART in third trimester. Participants were randomly assigned (1:1) to dolutegravir-based or efavirenz-based therapy. HIV viral load was measured 7 days and 28 days after antiretroviral initiation, at 36 weeks' gestation, and at the post-partum visit (0-14 days post partum). The primary efficacy outcome was a viral load of less than 50 copies per mL at the first post-partum visit, and the primary safety outcome was the occurrence of drug-related adverse events in mothers and infants until the post-partum visit. Longer-term follow-up of mothers and infants continues. This study is registered with ClinicalTrials.gov, NCT03249181. FINDINGS Between Jan 23, and Aug 15, 2018, we randomly assigned 268 mothers to dolutegravir (135) or efavirenz (133). All mothers and their infants were included in the safety analysis, and 250 mothers (125 in the dolutegravir group, 125 in the efavirenz group) and their infants in efficacy analyses, by intention-to-treat analyses. The median duration of maternal therapy at birth was 55 days (IQR 33-77). 89 (74%) of 120 in the dolutegravir group had viral loads less than 50 copies per mL, compared with 50 (43%) of 117 in the efavirenz group (risk ratio 1·64, 95% CI 1·31-2·06). 30 (22%) of 137 mothers in the dolutegravir group reported serious adverse events compared with 14 (11%) of 131 in the efavirenz group (p=0·013), particularly surrounding pregnancy and puerperium. We found no differences in births less than 37 weeks and less than 34 weeks gestation (16·4% vs 3·3%, across both groups). Three stillbirths in the dolutegravir group and one in the efavirenz group were considered unrelated to treatment. Three infant HIV infections were detected, all in the dolutegravir group, and were considered likely to be in-utero transmissions. INTERPRETATION Our data support the revision to WHO guidelines recommending the transition to dolutegravir in first-line ART for all adults, regardless of pregnancy or child-bearing potential. FUNDING Unitaid.
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Affiliation(s)
- Kenneth Kintu
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Thokozile R Malaba
- Division of Epidemiology and Biostatistics, University of Cape Town, Cape Town, South Africa
| | - Jesca Nakibuka
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Angela Colbers
- Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Kelly Byrne
- Tropical Clinical Trials Unit, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Kay Seden
- Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Eva Maria Hodel
- Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Tao Chen
- Tropical Clinical Trials Unit, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Adelline Twimukye
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Josaphat Byamugisha
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; Department of Gynaecology and Obstetrics School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Helen Reynolds
- Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK; Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Victoria Watson
- Tropical Clinical Trials Unit, Liverpool School of Tropical Medicine, Liverpool, UK
| | - David Burger
- Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Duolao Wang
- Tropical Clinical Trials Unit, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Catriona Waitt
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK; Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Miriam Taegtmeyer
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Catherine Orrell
- School of Public Health & Family Medicine, and Desmond Tutu HIV Centre, Department of Medicine, Institute of Infectious Diseases & Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Mohammed Lamorde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Landon Myer
- Division of Epidemiology and Biostatistics, University of Cape Town, Cape Town, South Africa; Centre for Infectious Diseases Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Saye Khoo
- Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK; Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK.
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Nallu R, Madhavan P, Chirch L, Luthra P. Thyroid Eye Disease due to Immune Reconstitution Inflammatory Syndrome as a Consequence of Antiretroviral Therapy in the Setting of AIDS. Case Rep Endocrinol 2020; 2020:1728423. [PMID: 32099691 DOI: 10.1155/2020/1728423] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 01/02/2020] [Accepted: 01/24/2020] [Indexed: 11/17/2022] Open
Abstract
We describe a case of worsening Graves' orbitopathy due to immune reconstitution inflammatory syndrome (IRIS) in a 38-year-old HIV-infected male after beginning ART (antiretroviral therapy). Two years after initiation of ART, the patient developed symptoms of hyperthyroidism and thyroid eye disease (TED) or Graves' orbitopathy (GO). Thyroid iodine uptake scan was consistent with Graves' disease. The CT scan of the orbits revealed minimal right-sided proptosis, consistent with GO. He was treated with methimazole and a short course of high-dose prednisone for GO. Thyroid function tests normalized, and eye symptoms eventually stabilized. This case demonstrates the importance of awareness and early recognition of IRIS in its many forms, as it has significant therapeutic implications.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Morare NMT, Rose DM, Appels O. Oesophageal tuberculosis with concomitant candidiasis: a rare cause of dysphagia. BMJ Case Rep 2019; 12:12/11/e231435. [PMID: 31678924 DOI: 10.1136/bcr-2019-231435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We present a case of a 23-year-old woman with dysphagia. She was reportedly newly diagnosed with HIV and had been initiated on antiretroviral treatment and tuberculosis (TB) prophylaxis. Oesophagogastroduodenoscopy revealed an irregular, ulcerative oesophageal lesion. Subsequent histopathology revealed M ycobacterium tuberculosis as well as C andida albicans A CT scan demonstrated widespread disease with miliary TB. She was subsequently initiated on antituberculous and antifungal medications. TB is one of the most common and deadly infectious diseases in the world, with the highest rates seen in the developing countries. It commonly occurs as an opportunistic infection of HIV. Despite its potential for systemic infection, infection of the oesophagus is incredibly rare, more so as a co-infection with candida. This case highlights the need to have a high index of suspicion in high risk groups, as early treatment is crucial in addressing this global health crisis.
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Affiliation(s)
- Nolitha Makapi Tisetso Morare
- Department of Surgery, Klerksdorp Tshepong Hospital Complex, Klerksdorp, North West, South Africa .,Department of Surgery, University of Witwatersrand, Johannesburg, Gauteng, South Africa
| | - David Morris Rose
- Department of Surgery, Klerksdorp Tshepong Hospital Complex, Klerksdorp, North West, South Africa
| | - Olivia Appels
- Department of Surgery, Klerksdorp Tshepong Hospital Complex, Klerksdorp, North West, South Africa
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Post FA, Szubert AJ, Prendergast AJ, Johnston V, Lyall H, Fitzgerald F, Musiime V, Musoro G, Chepkorir P, Agutu C, Mallewa J, Rajapakse C, Wilkes H, Hakim J, Mugyenyi P, Walker AS, Gibb DM, Pett SL. Causes and Timing of Mortality and Morbidity Among Late Presenters Starting Antiretroviral Therapy in the REALITY Trial. Clin Infect Dis 2019. [PMID: 29514234 PMCID: PMC5850430 DOI: 10.1093/cid/cix1141] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background In sub-Saharan Africa, 20%-25% of people starting antiretroviral therapy (ART) have severe immunosuppression; approximately 10% die within 3 months. In the Reduction of EArly mortaLITY (REALITY) randomized trial, a broad enhanced anti-infection prophylaxis bundle reduced mortality vs cotrimoxazole. We investigate the contribution and timing of different causes of mortality/morbidity. Methods Participants started ART with a CD4 count <100 cells/µL; enhanced prophylaxis comprised cotrimoxazole plus 12 weeks of isoniazid + fluconazole, single-dose albendazole, and 5 days of azithromycin. A blinded committee adjudicated events and causes of death as (non-mutually exclusively) tuberculosis, cryptococcosis, severe bacterial infection (SBI), other potentially azithromycin-responsive infections, other events, and unknown. Results Median pre-ART CD4 count was 37 cells/µL. Among 1805 participants, 225 (12.7%) died by week 48. Fatal/nonfatal events occurred early (median 4 weeks); rates then declined exponentially. One hundred fifty-four deaths had single and 71 had multiple causes, including tuberculosis in 4.5% participants, cryptococcosis in 1.1%, SBI in 1.9%, other potentially azithromycin-responsive infections in 1.3%, other events in 3.6%, and unknown in 5.0%. Enhanced prophylaxis reduced deaths from cryptococcosis and unknown causes (P < .05) but not tuberculosis, SBI, potentially azithromycin-responsive infections, or other causes (P > .3); and reduced nonfatal/fatal tuberculosis and cryptococcosis (P < .05), but not SBI, other potentially azithromycin-responsive infections, or other events (P > .2). Conclusions Enhanced prophylaxis reduced mortality from cryptococcosis and unknown causes and nonfatal tuberculosis and cryptococcosis. High early incidence of fatal/nonfatal events highlights the need for starting enhanced-prophylaxis with ART in advanced disease. Clinical Trials Registration ISRCTN43622374.
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Affiliation(s)
- Frank A Post
- King's College Hospital NHS Foundation Trust, London
| | | | | | | | | | - Felicity Fitzgerald
- University College London Great Ormond Street Institute of Child Health, United Kingdom
| | | | | | | | - Clara Agutu
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi
| | - Jane Mallewa
- Department of Medicine, College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre
| | | | - Helen Wilkes
- Medical Research Council Clinical Trials Unit at University College London
| | | | | | - A Sarah Walker
- Medical Research Council Clinical Trials Unit at University College London
| | - Diana M Gibb
- Medical Research Council Clinical Trials Unit at University College London
| | - Sarah L Pett
- Medical Research Council Clinical Trials Unit at University College London.,Institute for Global Health, University College London, United Kingdom.,Kirby Institute for Infection and Immunity in Society, University of New South Wales, Sydney, Australia
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Yin S, Xu Y, Huang J, Xiong N, Han C, Ma K, Guo XF, Xia Y, Wan F, Kou L, Sun Y, Wu J, Wang T. Immune Reconstitution Inflammatory Syndrome Secondary to Autoimmune Hemolytic Anemia and Cryptococcal Meningitis. Front Neurol 2019; 10:812. [PMID: 31447756 PMCID: PMC6691054 DOI: 10.3389/fneur.2019.00812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 07/15/2019] [Indexed: 11/13/2022] Open
Abstract
A 47-year-old HIV-seronegative woman with autoimmune hemolytic anemia (AIHA) was treated with corticosteroids for 8 months. She developed central nervous system dysfunction and was diagnosed with cryptococcal meningitis (CM) after detecting cryptococcus neoformans in the cerebrospinal fluid. The patient's clinical symptoms were worsened and unusual MRI findings of white matter lesions were noticed even after adequate treatment, which were quite unusual compared with typical characteristics of CM. This led us to carry out further investigations. Similar cases have been reported previously in published literature. Combined with clinical symptoms and MRI findings, the most likely diagnosis was Cryptococcal Meningitis-Immune Reconstitution Inflammatory Syndrome. Unfortunately, the patient deteriorated and died of respiratory failure. Cryptococcal Meningitis-Immune Reconstitution Inflammatory Syndrome may have MRI changes during the early onset of the disease (bilateral basal ganglia). We propose that close monitoring of the condition, meticulous MRI follow-up and brain biopsies should be indicated in such cases for treating them actively, so as to avoid worsening of the patients' condition.
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Affiliation(s)
- SiJia Yin
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yan Xu
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jinsha Huang
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Nian Xiong
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chao Han
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China,Department of Life Sciences and Medicine, The First Affiliated Hospital, University of Science and Technology of China, Hefei, China
| | - Kai Ma
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xing Fang Guo
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yun Xia
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fang Wan
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Liang Kou
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yadi Sun
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiawei Wu
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tao Wang
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China,*Correspondence: Tao Wang
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Abstract
PURPOSE OF REVIEW This article details the epidemiology and clinical manifestations of central nervous system (CNS) tuberculosis (TB), provides guidance for diagnostic imaging and CSF testing, and recommends treatment strategies for tuberculous meningitis and other forms of CNS TB, illustrating key aspects of diagnosis and management with case presentations. RECENT FINDINGS Although improvements in our understanding of the pathogenesis and management of CNS TB have occurred over the past 50 years, the emergence of multidrug-resistant and extensively drug-resistant TB, the advent of acquired immunodeficiency syndrome (AIDS), and the subsequent availability of highly active antiretroviral therapy that can produce the immune reconstitution inflammatory syndrome have complicated the diagnosis and treatment of CNS TB. Advances in diagnostic assays promise to increase the speed of diagnosis as well as the percentage of people with a confirmed rather than a presumptive diagnosis. Advances in precision medicine have identified polymorphisms in the LTA4H gene that influence the risk for inflammation in patients with tuberculous meningitis. SUMMARY CNS TB continues to be a major cause of morbidity and mortality, with the majority of people affected living in low-income and middle-income countries. Newer diagnostic assays promise to increase the speed of diagnosis and improve appropriate selection of antituberculous therapy and anti-inflammatory medications. Despite these advances, CNS TB remains difficult to diagnose, and clinicians should have a low threshold for initiating empiric therapy in patients with presumptive infection.
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Zöllner SK, Herbrüggen H, Kolve H, Mihailovic N, Schubert F, Reicherts C, Rössig C, Groll AH. Cytomegalovirus retinitis in children and adolescents with acute leukemia following allogeneic hematopoietic stem cell transplantation. Transpl Infect Dis 2019; 21:e13089. [PMID: 30972869 DOI: 10.1111/tid.13089] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/19/2019] [Accepted: 03/23/2019] [Indexed: 11/28/2022]
Abstract
Cytomegalovirus retinitis (CMVR) may occur after allogeneic hematopoietic stem cell transplantation (HSCT). However, little is known about its incidence, strategies for ophthalmic surveillance, and timely implementation of adequate antiviral treatment in pediatric allogeneic HSCT recipients. We provide a retrospective analysis of the epidemiology and clinical features of CMVR in pediatric allogeneic HSCT patients transplanted at our center over a 16-year period. Two patients of this cohort with leukemia are presented. Our analysis is supplemented by a systematic review on pediatric patients with leukemia and CMVR in the setting of allogeneic HSCT. The overall incidence of CMVR in our cohort was 1% (4/338) and 14.2% (3/21) in leukemic patients. In published cases, CMVR occurred at a median of 143 days after transplantation, and, in the majority of patients, was preceded by CMV detection in blood by a median of 93 days. Continued immune suppression following engraftment likely triggers CMVR. Preemptive treatment with ganciclovir as standard is usually successful. Foscarnet is used in case of resistance to ganciclovir or drug-induced granulocytopenia. Overall, CMVR after HSCT in pediatric leukemic patients is rare, but a potentially higher vulnerability of this population for involvement of the eye warrants a standardized ophthalmological examination plan.
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Affiliation(s)
- Stefan K Zöllner
- Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster, Muenster, Germany
| | - Heidrun Herbrüggen
- Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster, Muenster, Germany
| | - Hedwig Kolve
- Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster, Muenster, Germany.,Pharmacy Department, University Hospital Muenster, Muenster, Germany
| | - Natasa Mihailovic
- Department of Ophthalmology, University Hospital Muenster, Muenster, Germany
| | - Friederike Schubert
- Department of Ophthalmology, University Hospital Muenster, Muenster, Germany
| | | | - Claudia Rössig
- Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster, Muenster, Germany
| | - Andreas H Groll
- Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster, Muenster, Germany
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de Souza Campos Fernandes RC, Louvain de Souza T, da Silva Barcellos T, Medina-Acosta E. An Exclusively Skewed Distribution of Pediatric Immune Reconstitution Inflammatory Syndrome Toward the Female Sex Is Associated With Advanced Acquired Immune Deficiency Syndrome. Front Pediatr 2019; 7:293. [PMID: 31355171 PMCID: PMC6635464 DOI: 10.3389/fped.2019.00293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 06/28/2019] [Indexed: 11/29/2022] Open
Abstract
In human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS) patients with very low CD4 cell counts, there is a temporal relationship between administration of antiretroviral therapy (ART) and an increased inflammatory response state known as the immune reconstitution inflammatory syndrome (IRIS). The predominant clinical presentation of IRIS is an infectious disease that can be life-threatening. IRIS-related infectious events are distributed similarly between adult males and females, albeit a few studies have shown a skewing toward the male sex in pediatric IRIS. Here, we assessed sex-specific differences in the causes and extent of IRIS infectious events in HIV-infected pediatric patients on ART. We carried out a prospective clinical analysis (from 2000 to 2018) of IRIS-related infectious events after ART in a cohort of 82 Brazilian children and adolescents infected with HIV-1 through mother-to-child transmission as well as a comprehensive cross-referencing with public records on IRIS-related infectious causes in pediatric HIV/AIDS. Twelve events fulfilling the criteria of IRIS occurred exclusively in 11 females in our cohort. The median age at IRIS events was 3.6 years. The infectious causes included Mycobacterium bovis, varicella-zoster virus, molluscum contagiosum virus, human papillomavirus, cytomegalovirus, and Mycobacterium tuberculosis. In one female, there was regional bacillus Calmette-Guérin dissemination and cytomegalovirus esophagitis. There was complete health recovery after 10 IRIS events without the use of corticosteroids or ART interruption. One case of IRIS-associated miliary tuberculosis was fatal. The biological female sex was a significant risk factor for IRIS events (odds ratio: 23.67; 95% confidence interval 95%: 1.341-417.7; P = 0.0016 and P < 0.01 by the multivariable analysis). We observed an effect of the advanced HIV/AIDS variable in IRIS females as compared with non-IRIS females (mean CD4+ T cell percentage 13.36 vs. 18.63%; P = 0.0489 and P < 0.05 by the multivariable analysis), underpinning the exclusively skewed distribution toward the female sex of this cohort. Moreover, the IRIS females in our cohort had higher mean CD4+ T cell percentages before (13.36%) and after IRIS (26.56%) than those of the IRIS females (before IRIS, 4.978%; after IRIS, 13.81%) in previous studies conducted worldwide. The exclusively skewed distribution of pediatric IRIS toward the female sex in the cohort was not linked to preferential X-chromosome inactivation rates. We concluded that the exclusively skewed distribution of pediatric IRIS toward females is associated with more advanced AIDS.
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Affiliation(s)
- Regina Célia de Souza Campos Fernandes
- Faculty of Medicine of Campos, Campos dos Goytacazes, Brazil.,Municipal Program for the Surveillance of Sexually Transmitted Diseases and Acquired Immunodeficiency Syndrome of Campos dos Goytacazes, Campos dos Goytacazes, Brazil.,Molecular Identification and Diagnosis Unit, Laboratory of Biotechnology, Center for Biosciences and Biotechnology, Universidade Estadual do Norte Fluminense Darcy Ribeiro, Campos dos Goytacazes, Brazil
| | - Thaís Louvain de Souza
- Faculty of Medicine of Campos, Campos dos Goytacazes, Brazil.,Molecular Identification and Diagnosis Unit, Laboratory of Biotechnology, Center for Biosciences and Biotechnology, Universidade Estadual do Norte Fluminense Darcy Ribeiro, Campos dos Goytacazes, Brazil
| | | | - Enrique Medina-Acosta
- Molecular Identification and Diagnosis Unit, Laboratory of Biotechnology, Center for Biosciences and Biotechnology, Universidade Estadual do Norte Fluminense Darcy Ribeiro, Campos dos Goytacazes, Brazil
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Kityo C, Szubert AJ, Siika A, Heyderman R, Bwakura-Dangarembizi M, Lugemwa A, Mwaringa S, Griffiths A, Nkanya I, Kabahenda S, Wachira S, Musoro G, Rajapakse C, Etyang T, Abach J, Spyer MJ, Wavamunno P, Nyondo-Mipando L, Chidziva E, Nathoo K, Klein N, Hakim J, Gibb DM, Walker AS, Pett SL. Raltegravir-intensified initial antiretroviral therapy in advanced HIV disease in Africa: A randomised controlled trial. PLoS Med 2018; 15:e1002706. [PMID: 30513108 PMCID: PMC6279020 DOI: 10.1371/journal.pmed.1002706] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 10/29/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND In sub-Saharan Africa, individuals infected with HIV who are severely immunocompromised have high mortality (about 10%) shortly after starting antiretroviral therapy (ART). This group also has the greatest risk of morbidity and mortality associated with immune reconstitution inflammatory syndrome (IRIS), a paradoxical response to successful ART. Integrase inhibitors lead to significantly more rapid declines in HIV viral load (VL) than all other ART classes. We hypothesised that intensifying standard triple-drug ART with the integrase inhibitor, raltegravir, would reduce HIV VL faster and hence reduce early mortality, although this strategy could also risk more IRIS events. METHODS AND FINDINGS In a 2×2×2 factorial open-label parallel-group trial, treatment-naive adults, adolescents, and children >5 years old infected with HIV, with cluster of differentiation 4 (CD4) <100 cells/mm3, from eight urban/peri-urban HIV clinics at regional hospitals in Kenya, Malawi, Uganda, and Zimbabwe were randomised 1:1 to initiate standard triple-drug ART, with or without 12-week raltegravir intensification, and followed for 48 weeks. The primary outcome was 24-week mortality, analysed by intention to treat. Of 2,356 individuals screened for eligibility, 1,805 were randomised between 18 June 2013 and 10 April 2015. Of the 1,805 participants, 961 (53.2%) were male, 72 (4.0%) were children/adolescents, median age was 36 years, CD4 count was 37 cells/mm3, and plasma viraemia was 249,770 copies/mL. Fifty-six participants (3.1%) were lost to follow-up at 48 weeks. By 24 weeks, 97/902 (10.9%) raltegravir-intensified ART versus 91/903 (10.2%) standard ART participants had died (adjusted hazard ratio [aHR] = 1.10 [95% CI 0.82-1.46], p = 0.53), with no evidence of interaction with other randomisations (pheterogeneity > 0.7) and despite significantly greater VL suppression with raltegravir-intensified ART at 4 weeks (343/836 [41.0%] versus 113/841 [13.4%] with standard ART, p < 0.001) and 12 weeks (567/789 [71.9%] versus 415/803 [51.7%] with standard ART, p < 0.001). Through 48 weeks, there was no evidence of differences in mortality (aHR = 0.98 [95% CI 0.76-1.28], p = 0.91); in serious (aHR = 0.99 [0.81-1.21], p = 0.88), grade-4 (aHR = 0.88 [0.71-1.09], p = 0.29), or ART-modifying (aHR = 0.90 [0.63-1.27], p = 0.54) adverse events (the latter occurring in 59 [6.5%] participants with raltegravir-intensified ART versus 66 [7.3%] with standard ART); in events judged compatible with IRIS (occurring in 89 [9.9%] participants with raltegravir-intensified ART versus 86 [9.5%] with standard ART, p = 0.79) or in hospitalisations (aHR = 0.94 [95% CI 0.76-1.17], p = 0.59). At 12 weeks, one and two raltegravir-intensified participants had predicted intermediate-level and high-level raltegravir resistance, respectively. At 48 weeks, the nucleoside reverse transcriptase inhibitor (NRTI) mutation K219E/Q (p = 0.004) and the non-nucleoside reverse transcriptase inhibitor (NNRTI) mutations K101E/P (p = 0.03) and P225H (p = 0.007) were less common in virus from participants with raltegravir-intensified ART, with weak evidence of less intermediate- or high-level resistance to tenofovir (p = 0.06), abacavir (p = 0.08), and rilpivirine (p = 0.07). Limitations of the study include limited clinical, radiological, and/or microbiological information for some participants, reflecting available services at the centres, and lack of baseline genotypes. CONCLUSIONS Although 12 weeks of raltegravir intensification was well tolerated and reduced HIV viraemia significantly faster than standard triple-drug ART during the time of greatest risk for early death, this strategy did not reduce mortality or clinical events in this group and is not warranted. There was no excess of IRIS-compatible events, suggesting that integrase inhibitors can be used safely as part of standard triple-drug first-line therapy in severely immunocompromised individuals. TRIAL REGISTRATION ClinicalTrials.gov NCT01825031. TRIAL REGISTRATION International Standard Randomised Controlled Trials Number ISRCTN 43622374.
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Affiliation(s)
- Cissy Kityo
- Joint Clinical Research Centre, Kampala, Uganda
| | - Alexander J. Szubert
- Medical Research Council Clinical Trials Unit at University College London, University College London, London, United Kingdom
| | | | - Robert Heyderman
- Department/College of Medicine, University of Malawi, and Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Division of Infection and Immunity, University College London, London, United Kingdom
| | | | | | | | - Anna Griffiths
- Medical Research Council Clinical Trials Unit at University College London, University College London, London, United Kingdom
| | | | | | | | - Godfrey Musoro
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | - Chatu Rajapakse
- Medical Research Council Clinical Trials Unit at University College London, University College London, London, United Kingdom
| | | | - James Abach
- Joint Clinical Research Centre, Gulu, Uganda
| | - Moira J. Spyer
- Medical Research Council Clinical Trials Unit at University College London, University College London, London, United Kingdom
| | | | - Linda Nyondo-Mipando
- Department/College of Medicine, University of Malawi, and Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Ennie Chidziva
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | - Kusum Nathoo
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | - Nigel Klein
- University College London Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - James Hakim
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | - Diana M. Gibb
- Medical Research Council Clinical Trials Unit at University College London, University College London, London, United Kingdom
| | - A. Sarah Walker
- Medical Research Council Clinical Trials Unit at University College London, University College London, London, United Kingdom
| | - Sarah L. Pett
- Medical Research Council Clinical Trials Unit at University College London, University College London, London, United Kingdom
- Institute for Global Health, University College London, London, United Kingdom
- Kirby Institute for Infection and Immunity in Society, University of New South Wales, Sydney, Australia
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Pang W, Shang P, Li Q, Xu J, Bi L, Zhong J, Pei X. Prevalence of Opportunistic Infections and Causes of Death among Hospitalized HIV-Infected Patients in Sichuan, China. TOHOKU J EXP MED 2018; 244:231-242. [PMID: 29563388 DOI: 10.1620/tjem.244.231] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Opportunistic infections (OIs) are the most significant complication of human immunodeficiency virus (HIV) infection. The prevalence of OIs differs among various countries in part due to different climates and socio-economic conditions. We, therefore, carried out the retrospective study at the Public Health Clinical Center of Chengdu, Sichuan to comprehensively investigate the prevalence of OIs, predictors of OIs, and risk factors for in-hospital death among HIV-infected patients. Sichuan in West China is characterized by the largest population living with HIV/Acquired immunodeficiency syndrome (AIDS) across China. In total, we reviewed 954 cases of HIV infection, admitted to the hospital during January 2014 to December 2015, and found that bacterial pneumonia (25.8%) was the most common OIs, followed by candida infection (18.3%), Pneumocystis jiroveci pneumonia (11.9%), tuberculosis (11.5%), infectious diarrhoea (9.3%), cryptococcus infection (7.3%), cytomegalovirus infection (4.9%), toxoplasmosis (4.6%), hepatitis C (4.0%), nontuberculous mycobacteria desease (2.2%) and Penicillium marneffei infection (0.3%). We also found two strongest risk factors for in-hospital mortality: CD4+T cell counts of less than 100 cells/μL and not receiving antiretroviral therapy. Moreover, the study revealed the specific pathogens causing bacterial pneumonia and/or candida infection, the effect of tuberculosis on CD4+T cell counts, and the drug resistance of Mycobacterium tuberculosis among HIV-infected and non-HIV-infected patients. The present findings may aid in the clinical diagnosis and treatment of HIV-infected patients, and could help developing efficient public health strategies in China.
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Affiliation(s)
- Wenwen Pang
- Department of West China School of Public Health, No.4 West China Teaching Hospital, Sichuan University
| | - Pengcheng Shang
- Department of Laboratory, Public Health Clinical Center of Chengdu
| | - Qingfeng Li
- Department of Laboratory, Public Health Clinical Center of Chengdu
| | - Jiao Xu
- Department of Laboratory, Public Health Clinical Center of Chengdu
| | - Lei Bi
- Department of Laboratory, Public Health Clinical Center of Chengdu
| | - Jing Zhong
- Department of Laboratory, Public Health Clinical Center of Chengdu
| | - Xiaofang Pei
- Department of West China School of Public Health, No.4 West China Teaching Hospital, Sichuan University
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Topiwala M, Dubale N, Medisetty MK, Gaikwad S, Patel D, Pujari S. AIDS Cholangiopathy Secondary to Cytomegalovirus as Possible Unmasking Immune Reconstitution Inflammatory Syndrome in Human Immunodeficiency Virus-Infected Individual: Case Report and Review of the Literature. Case Rep Infect Dis 2018; 2018:1891030. [PMID: 30147971 DOI: 10.1155/2018/1891030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 07/10/2018] [Indexed: 11/17/2022] Open
Abstract
We present the first case report of cytomegalovirus (CMV) cholangiopathy as possible immune reconstitution inflammatory syndrome (IRIS) in a human immunodeficiency virus (HIV)-infected individual, within two months of starting effective HAART. The patient presented with abdominal pain, nausea, vomiting, decreased appetite, and jaundice. The patient was diagnosed on ERCP as AIDS cholangiopathy, and biopsy of the ampulla showed acute inflammation with CMV inclusion bodies. The patient underwent sphincterotomy with CBD stenting and HAART continued without use of ganciclovir or valganciclovir. On follow-up, the patient achieved clinical and histopathological cure, which was demonstrated on repeat ampullary biopsy.
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