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Shishido-Hara Y, Akimoto J, Fukami S, Kohno M, Matsubayashi J, Nagao T. Pathology for severe inflammatory PML with PD1/PD-L1 expression of favorable prognosis: What's a prognostic factor for PML-IRIS? Neuropathology 2024; 44:47-58. [PMID: 37424276 DOI: 10.1111/neup.12929] [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: 04/17/2023] [Revised: 05/24/2023] [Accepted: 06/05/2023] [Indexed: 07/11/2023]
Abstract
A 72-year-old woman with dermatomyositis (DM) developed neurological manifestation, and magnetic resonance imaging (MRI) revealed multiple T2/fluid-attenuated inversion recovery (FLAIR)-hyperintense lesions predominantly in the deep white matter of the cerebral hemisphere. Punctate or linear contrast enhancement was observed surrounding the T1-hypointense area. Multiple T2/FLAIR-hyperintense lesions were aligned along with the corona radiata. Malignant lymphoma was first suspected, and a brain biopsy was performed. Pathological investigation suggested the provisional diagnosis of "suspicious of malignant lymphoma." Owing to emergent clinical conditions, high-dose methotrexate (MTX) therapy was conducted, and then T2/FLAIR-hyperintense lesions were dramatically reduced. However, the diagnosis of malignant lymphoma was concerning since multiplex PCR demonstrated clonal restriction of the Ig H gene for B cells and TCR beta genes for T cells. Histopathology revealed the infiltration of both CD4+ and CD8+ T cells, and the CD4+ /CD8+ ratio was 4.0. Moreover, prominent plasma cells were observed, in addition to CD20+ B cells. Atypical cells with enlarged nuclei were present, and they were not hematopoietic but found as glial cells. JC virus (JCV) infection was verified with both immunohistochemistry and in situ hybridization; the final diagnosis was progressive multifocal leukoencephalopathy (PML). The patient was treated with mefloquine and discharged. This case is informative in understanding the host anti-viral response. Variable inflammatory cells were observed, including CD4+ and CD8+ T cells, plasma cells, and a small amount of perivascular CD20+ B cells. PD-1 and PD-L1 expression was observed in lymphoid cells and macrophages, respectively. PML with inflammatory reactions was thought fatal, and autopsy cases of PML with immune reconstitution inflammatory syndrome (IRIS) demonstrated excessive infiltration of only CD8+ T cells. However, this case revealed infiltration of variable inflammatory cells, and a favorable prognosis would be expected under PD-1/PD-L1 immune-checkpoint regulation.
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Affiliation(s)
- Yukiko Shishido-Hara
- Department of Anatomic Pathology, Tokyo Medical University, Tokyo, Japan
- Department of Pathology and Applied Neurobiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Jiro Akimoto
- Department of Neurosurgery, Tokyo Medical University, Tokyo, Japan
| | - Shinjiro Fukami
- Department of Neurosurgery, Tokyo Medical University, Tokyo, Japan
| | - Michihiro Kohno
- Department of Neurosurgery, Tokyo Medical University, Tokyo, Japan
| | - Jun Matsubayashi
- Department of Anatomic Pathology, Tokyo Medical University, Tokyo, Japan
| | - Toshitaka Nagao
- Department of Anatomic Pathology, Tokyo Medical University, Tokyo, Japan
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2
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Makino H, Tohyama M, Kawamura R, Takata Y, Osawa H, Onuma H. Fulminant type 1 diabetes caused by DIHS could be affected by the reactivation of HHV-6. J Clin Endocrinol Metab 2024:dgae058. [PMID: 38298135 DOI: 10.1210/clinem/dgae058] [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: 10/15/2023] [Revised: 12/29/2023] [Accepted: 01/26/2024] [Indexed: 02/02/2024]
Abstract
CONTEXT In the previous issue of this journal, we reported that the incidence of fulminant type 1 diabetes (FT1D) due to the drug-induced hypersensitivity syndrome (DIHS) in Japan is higher than that in the general population and is associated with HLAB62. On the other hand, the reactivation of human herpesvirus 6 (HHV-6), which has been reported to be associated with DIHS, was observed at a higher frequency, but its association with the development of FT1D was unclear. OBJECTIVE We aimed to clarify the relationship between the onset of FT1D and the reactivation of HHV-6. METHODS We conducted a literature search for cases of DIHS-induced FT1D in addition to previously reported cases, and investigated the changes in the HHV-6 antibody titer before and after the onset of FT1D. RESULTS The HHV-6 antibody titer was increased just before or after the onset of FT1D in all 8 cases. In one case, HHV-6 DNA was also identified shortly before the onset of FT1D. CONCLUSION These results indicate for the first time that the reactivation of HHV-6 is associated with the onset of FT1D caused by DIHS. .
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Affiliation(s)
- Hideichi Makino
- Department of Diabetes and Molecular Genetics, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Mikiko Tohyama
- Department of Dermatology, National Hospital Organization Shikoku Cancer Center, Ehime, Japan
| | - Ryoichi Kawamura
- Department of Diabetes and Molecular Genetics, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Yasunori Takata
- Department of Diabetes and Molecular Genetics, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Haruhiko Osawa
- Department of Diabetes and Molecular Genetics, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Hiroshi Onuma
- Department of Diabetes and Molecular Genetics, Ehime University Graduate School of Medicine, Ehime, Japan
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3
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Dangarembizi R, Drummond R. Immune-related neurodegeneration in the midbrain causes pulmonary dysfunction in murine cryptococcal IRIS. Trends Neurosci 2023; 46:1003-1004. [PMID: 37806831 DOI: 10.1016/j.tins.2023.09.005] [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: 09/03/2023] [Accepted: 09/22/2023] [Indexed: 10/10/2023]
Abstract
Cryptococcal immune reconstitution inflammatory syndrome (C-IRIS) is a condition that affects immunosuppressed individuals recruited to antiretroviral therapy. In a recent publication, Kawano and colleagues used a mouse model to demonstrate that pulmonary dysfunction, one of the fatal complications of C-IRIS, is caused by T cell-driven neurodegeneration in a vital medullary nucleus of the brain responsible for respiratory control.
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Affiliation(s)
- Rachael Dangarembizi
- Division of Physiological Sciences, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Neuroscience Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; CMM AFRICA Medical Mycology Research Unit, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Rebecca Drummond
- Institute of Immunology & Immunotherapy, University of Birmingham, Birmingham, UK
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4
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Yakushina TI, Yakushin DM, Shtang IO. [Differential diagnosis of immune reconstitution inflammatory syndrome and progressive multifocal leukoencephalopathy after natalizumab withdrawal]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:116-121. [PMID: 36946407 DOI: 10.17116/jnevro2023123031116] [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: 03/23/2023]
Abstract
The appearance of new foci on MRI, the increase in neurological deficits, including the appearance of cognitive disorders and disturbances in the level of consciousness in patients with multiple sclerosis during the «washing period» when transferring from natalizumab (NZ) to another drug, may be due to both progressive multifocal leukoencephalopathy (PML) and exacerbation of the disease in the absence of therapy. Discontinuation of NS is fraught not only with a resumption, but with an increase in disease activity, the development of an immune reconstitution inflammatory syndrome (IRIS) due to the opening of the blood-brain barrier. Often, the processes of differential diagnosis of IRIS and natalizumab-associated PML are complex and require the use of additional methods of examination and monitoring of the dynamics of the patient's condition. However, the severity of the condition and the severity of the consequences caused by incorrect therapeutic tactics significantly reduce the time for diagnosis and require an immediate decision. The difficulties of differential diagnosis of IRIS and PML are reflected in the clinical case.
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Affiliation(s)
- T I Yakushina
- Vladimirsky Moscow Regional Research Clinical Institute, Moscow, Russia
| | - D M Yakushin
- Vladimirsky Moscow Regional Research Clinical Institute, Moscow, Russia
| | - I O Shtang
- Vladimirsky Moscow Regional Research Clinical Institute, Moscow, Russia
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5
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Zaltron S, Cambianica A, Di Gregorio M, Colangelo C, Storti S, Tiecco G, Castelli F, Quiros-Roldan E. Case report: An occult hepatitis B virus infection reactivation in an HIV/HCV coinfected patient during an immune reconstitution inflammatory syndrome. Front Cell Infect Microbiol 2023; 13:1143346. [PMID: 37124041 PMCID: PMC10145166 DOI: 10.3389/fcimb.2023.1143346] [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: 01/27/2023] [Accepted: 03/24/2023] [Indexed: 05/02/2023] Open
Abstract
The natural history of occult hepatitis B virus infection (OBI) and the mechanism involved in HBV reactivation are only partially understood. As regards people living with HIV (PLWH), HBV reactivation is estimated to occur with an incidence ratio of 0.019 cases per 100 person-year. Here we report the case of OBI reactivation in a HIV/HCV co-infected patient followed for 25 years at our Infectious Diseases Unit, but, unfortunately, lost to follow-up about 19 months after Direct-acting antivirals (DAAs) treatment. At re-engagement, blood tests showed high replication of plasmatic HIV-RNA along with severe immunosuppression and normal levels of liver enzymes. However, 3 months after ART reintroduction, an immune reconstitution inflammatory syndrome (IRIS) was diagnosed with high detectable HBV-DNA load and transaminase elevation. Our case report shows how the balance between the virus and the host immune system is quite a dynamic process that might significantly impact the course of the disease. The aim of this case report is to bring to the attention of physicians that, although OBI reactivation is a rather rare occurrence, even amongst PLWH, its potential consequences compel to a high alertness on the matter. Therefore, especially in patients with an impaired immune system and on a tenofovir or lamivudine-sparing regimen, HBV serological and virological markers should always be strictly monitored, even in the absence of a hepatitis flare.
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Affiliation(s)
- Serena Zaltron
- Unit of Infectious and Tropical Diseases, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Anna Cambianica
- Unit of Infectious and Tropical Diseases, Department of Clinical and Experimental Sciences, ASST Spedali Civili di Brescia and University of Brescia, Brescia, Italy
| | - Marco Di Gregorio
- Unit of Infectious and Tropical Diseases, Department of Clinical and Experimental Sciences, ASST Spedali Civili di Brescia and University of Brescia, Brescia, Italy
| | - Cosimo Colangelo
- Unit of Infectious and Tropical Diseases, Department of Clinical and Experimental Sciences, ASST Spedali Civili di Brescia and University of Brescia, Brescia, Italy
| | - Samuele Storti
- Unit of Infectious and Tropical Diseases, Department of Clinical and Experimental Sciences, ASST Spedali Civili di Brescia and University of Brescia, Brescia, Italy
| | - Giorgio Tiecco
- Unit of Infectious and Tropical Diseases, Department of Clinical and Experimental Sciences, ASST Spedali Civili di Brescia and University of Brescia, Brescia, Italy
| | - Francesco Castelli
- Unit of Infectious and Tropical Diseases, Department of Clinical and Experimental Sciences, ASST Spedali Civili di Brescia and University of Brescia, Brescia, Italy
| | - Eugenia Quiros-Roldan
- Unit of Infectious and Tropical Diseases, Department of Clinical and Experimental Sciences, ASST Spedali Civili di Brescia and University of Brescia, Brescia, Italy
- *Correspondence: Eugenia Quiros-Roldan,
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6
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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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Pei L, Fukutani KF, Tibúrcio R, Rupert A, Dahlstrom EW, Galindo F, Laidlaw E, Lisco A, Manion M, Andrade BB, Sereti I. Plasma Metabolomics Reveals Dysregulated Metabolic Signatures in HIV-Associated Immune Reconstitution Inflammatory Syndrome. Front Immunol 2021; 12:693074. [PMID: 34211479 PMCID: PMC8239348 DOI: 10.3389/fimmu.2021.693074] [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: 04/09/2021] [Accepted: 05/27/2021] [Indexed: 12/17/2022] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) is an inflammatory complication associated with an underlying opportunistic infection that can be observed in HIV-infected individuals shortly after the initiation of antiretroviral therapy, despite successful suppression of HIV viral load and CD4+ T cell recovery. Better understanding of IRIS pathogenesis would allow for targeted prevention and therapeutic approaches. In this study, we sought to evaluate the metabolic perturbations in IRIS across longitudinal time points using an unbiased plasma metabolomics approach as well as integrated analyses to include plasma inflammatory biomarker profile and whole blood transcriptome. We found that many lipid and amino acid metabolites differentiated IRIS from non-IRIS conditions prior to antiretroviral therapy and during the IRIS event, implicating the association between oxidative stress, tryptophan pathway, and lipid mediated signaling and the development of IRIS. Lipid and amino acid metabolic pathways also significantly correlated with inflammatory biomarkers such as IL-12p70 and IL-8 at the IRIS event, indicating the role of cellular metabolism on cell type specific immune activation during the IRIS episode and in turn the impact of immune activation on cellular metabolism. In conclusion, we defined the metabolic profile of IRIS and revealed that perturbations in metabolism may predispose HIV-infected individuals to IRIS development and contribute to the inflammatory manifestations during the IRIS event. Furthermore, our findings expanded our current understanding IRIS pathogenesis and highlighted the significance of lipid and amino acid metabolism in inflammatory complications.
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Affiliation(s)
- Luxin Pei
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, United States.,Department of Biology, Johns Hopkins University, Baltimore, MD, United States
| | - Kiyoshi F Fukutani
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil.,Laboratory of Inflammation and Biomarkers, Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador, Brazil.,Curso de Medicina, Centro Universitário Faculdade de Tecnologia e Ciências (UniFTC), Salvador, Brazil
| | - Rafael Tibúrcio
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil.,Laboratory of Inflammation and Biomarkers, Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador, Brazil.,Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil
| | - Adam Rupert
- Leidos Biomedical Research Inc., Frederick National Laboratory for Cancer Research, Frederick, MD, United States
| | - Eric W Dahlstrom
- Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Hamilton, MT, United States
| | - Frances Galindo
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, United States
| | - Elizabeth Laidlaw
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, United States
| | - Andrea Lisco
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, United States
| | - Maura Manion
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, United States
| | - Bruno B Andrade
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil.,Laboratory of Inflammation and Biomarkers, Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador, Brazil.,Curso de Medicina, Centro Universitário Faculdade de Tecnologia e Ciências (UniFTC), Salvador, Brazil.,Faculdade de Medicina, Universidade Federal da Bahia, 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.,Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Irini Sereti
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, United States
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8
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Araújo GRDS, Alves V, Martins-de-Souza PH, Guimarães AJ, Honorato L, Nimrichter L, Takiya CM, Pontes B, Frases S. Dexamethasone and Methylprednisolone Promote Cell Proliferation, Capsule Enlargement, and in vivo Dissemination of C. neoformans. Front Fungal Biol 2021; 2:643537. [PMID: 37744119 PMCID: PMC10512211 DOI: 10.3389/ffunb.2021.643537] [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] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 01/19/2021] [Indexed: 09/26/2023]
Abstract
Cryptococcus neoformans is a fungal pathogen that causes life-threatening infections in immunocompromised individuals, who often have some inflammatory condition and, therefore, end up using glucocorticoids, such as dexamethasone and methylprednisolone. Although the effects of this class of molecules during cryptococcosis have been investigated, their consequences for the biology of C. neoformans is less explored. Here, we studied the effects of dexamethasone and methylprednisolone on the metabolism and on the induction of virulence factors in C. neoformans. Our results showed that both glucocorticoids increased fungal cell proliferation and surface electronegativity but reduced capsule and secreted polysaccharide sizes, as well as capsule compaction, by decreasing the density of polysaccharide fibers. We also tested whether glucocorticoids could affect the fungal virulence in Galleria mellonella and mice. Although the survival rate of Galleria larvae increased, those from mice showed a tendency to decrease, with infected animals dying earlier after glucocorticoid treatments. The pathogenesis of spread of cryptococcosis and the interleukin secretion pattern were also assessed for lungs and brains of infected mice. While increases in the spread of the fungus to lungs were observed after treatment with glucocorticoids, a significant difference in brain was observed only for methylprednisolone, although a trend toward increasing was also observed for dexamethasone. Moreover, increases in both pulmonary and cerebral IL-10 production, reduction of IL-6 production but no changes in IL-4, IL-17, and INF-γ were also observed after glucocorticoid treatments. Finally, histopathological analysis confirmed the increase in number of fungal cells in lung and brain tissues of mice previously subjected to dexamethasone or methylprednisolone treatments. Together, our results provide compelling evidence for the effects of dexamethasone and methylprednisolone on the biology of C. neoformans and may have important implications for future clinical treatments, calling attention to the risks of using these glucocorticoids against cryptococcosis or in immunocompromised individuals.
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Affiliation(s)
- Glauber R. de S. Araújo
- Laboratório de Ultraestrutura Cellular Hertha Meyer, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal Do Rio de Janeiro, Rio de Janeiro, Brazil
- Laboratório de Biofísica de Fungos, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal Do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Vinicius Alves
- Laboratório de Ultraestrutura Cellular Hertha Meyer, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal Do Rio de Janeiro, Rio de Janeiro, Brazil
- Laboratório de Biofísica de Fungos, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal Do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Pedro H. Martins-de-Souza
- Laboratório de Ultraestrutura Cellular Hertha Meyer, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal Do Rio de Janeiro, Rio de Janeiro, Brazil
- Laboratório de Biofísica de Fungos, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal Do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Allan J. Guimarães
- Laboratório de Bioquímica e Imunologia das Micoses, Depto. de Microbiologia e Parasitologia, Instituto Biomédico, Universidade Federal Fluminense, Niterói, Brazil
| | - Leandro Honorato
- Instituto de Microbiologia Paulo de Góes, Universidade Federal Do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Leonardo Nimrichter
- Instituto de Microbiologia Paulo de Góes, Universidade Federal Do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Christina Maeda Takiya
- Laboratório de Imunopatologia. Instituto de Biofísica Carlos Chagas Filho, Universidade Federal Do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Bruno Pontes
- Instituto de Ciências Biomédicas, Universidade Federal Do Rio de Janeiro, Rio de Janeiro, Brazil
- Centro Nacional de Biologia Estrutural e Bioimagem (CENABIO), Universidade Federal Do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Susana Frases
- Laboratório de Ultraestrutura Cellular Hertha Meyer, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal Do Rio de Janeiro, Rio de Janeiro, Brazil
- Laboratório de Biofísica de Fungos, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal Do Rio de Janeiro, Rio de Janeiro, Brazil
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Brienze VMS, André JC, Liso E, Louis IV. Cryptococcal Immune Reconstitution Inflammatory Syndrome: From Blood and Cerebrospinal Fluid Biomarkers to Treatment Approaches. Life (Basel) 2021; 11:95. [PMID: 33514007 DOI: 10.3390/life11020095] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 12/20/2020] [Revised: 01/20/2021] [Accepted: 01/23/2021] [Indexed: 12/31/2022] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) presents as an exaggerated immune reaction that occurs during dysregulated immune restoration in immunocompromised patients in late-stage human immunodeficiency virus (HIV) infection who have commenced antiretroviral treatments (ART). Virtually any opportunistic pathogen can provoke this type of immune restoration disorder. In this review, we focus on recent developments in the identification of risk factors for Cryptococcal IRIS and on advancements in our understanding of C-IRIS immunopathogenesis. We overview new findings in blood and cerebrospinal fluid which can potentially be useful in the prediction and diagnosis of cryptococcal meningitis IRIS (CM-IRIS). We assess current therapeutic regimens and novel treatment approaches to combat CM-IRIS. We discuss the utility of biomarkers for clinical monitoring and adjusting treatment modalities in acquired immunodeficiency syndrome (AIDS) patients co-infected with Cryptococcus who have initiated ART.
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Vinhaes CL, Araujo-Pereira M, Tibúrcio R, Cubillos-Angulo JM, Demitto FO, Akrami KM, Andrade BB. Systemic Inflammation Associated with Immune Reconstitution Inflammatory Syndrome in Persons Living with HIV. Life (Basel) 2021; 11:life11010065. [PMID: 33477581 PMCID: PMC7831327 DOI: 10.3390/life11010065] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 11/16/2020] [Revised: 01/13/2021] [Accepted: 01/14/2021] [Indexed: 12/19/2022] Open
Abstract
Antiretroviral therapy (ART) has represented a major advancement in the care of people living with HIV (PLWHH), resulting in significant reductions in morbidity and mortality through immune reconstitution and attenuation of homeostatic disruption. Importantly, restoration of immune function in PLWH with opportunistic infections occasionally leads to an intense and uncontrolled cytokine storm following ART initiation known as immune reconstitution inflammatory syndrome (IRIS). IRIS occurrence is associated with the severe and rapid clinical deterioration that results in significant morbidity and mortality. Here, we detail the determinants underlying IRIS development in PLWH, compiling the available knowledge in the field to highlight details of the inflammatory responses in IRIS associated with the most commonly reported opportunistic pathogens. This review also highlights gaps in the understanding of IRIS pathogenesis and summarizes therapeutic strategies that have been used for IRIS.
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Affiliation(s)
- Caian L. Vinhaes
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador 40296-710, Brazil; (C.L.V.); (M.A.-P.); (R.T.); (J.M.C.-A.); (K.M.A.)
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador 40210-320, Brazil;
- Bahiana School of Medicine and Public Health, Bahia Foundation for the Development of Sciences, Salvador 40290-000, Brazil
| | - Mariana Araujo-Pereira
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador 40296-710, Brazil; (C.L.V.); (M.A.-P.); (R.T.); (J.M.C.-A.); (K.M.A.)
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador 40210-320, Brazil;
- Faculdade de Medicina, Universidade Federal da Bahia, Salvador 40110-100, Brazil
| | - Rafael Tibúrcio
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador 40296-710, Brazil; (C.L.V.); (M.A.-P.); (R.T.); (J.M.C.-A.); (K.M.A.)
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador 40210-320, Brazil;
- Faculdade de Medicina, Universidade Federal da Bahia, Salvador 40110-100, Brazil
| | - Juan M. Cubillos-Angulo
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador 40296-710, Brazil; (C.L.V.); (M.A.-P.); (R.T.); (J.M.C.-A.); (K.M.A.)
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador 40210-320, Brazil;
- Faculdade de Medicina, Universidade Federal da Bahia, Salvador 40110-100, Brazil
| | - Fernanda O. Demitto
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador 40210-320, Brazil;
| | - Kevan M. Akrami
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador 40296-710, Brazil; (C.L.V.); (M.A.-P.); (R.T.); (J.M.C.-A.); (K.M.A.)
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador 40210-320, Brazil;
- Faculdade de Medicina, Universidade Federal da Bahia, Salvador 40110-100, Brazil
- Divisions of Infectious Diseases and Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California, San Diego, CA 92093, USA
| | - Bruno B. Andrade
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador 40296-710, Brazil; (C.L.V.); (M.A.-P.); (R.T.); (J.M.C.-A.); (K.M.A.)
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador 40210-320, Brazil;
- Bahiana School of Medicine and Public Health, Bahia Foundation for the Development of Sciences, Salvador 40290-000, Brazil
- Faculdade de Medicina, Universidade Federal da Bahia, Salvador 40110-100, Brazil
- Curso de Medicina, Centro Universitário Faculdade de Tecnologia e Ciências (UniFTC), Salvador 41741-590, Brazil
- Correspondence: ; Tel.: +55-71-3176-2264
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Maximova N, Marcuzzi A, Del Rizzo I, Zanon D, Maestro A, Barbi E, Sala R. Standard treatment-refractory cytomegalovirus encephalitis unmasked by immune reconstitution inflammatory syndrome and successfully treated with virus-specific hyperimmune globulin. Clin Transl Immunology 2020; 9:e1201. [PMID: 33235734 PMCID: PMC7670254 DOI: 10.1002/cti2.1201] [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: 05/18/2020] [Revised: 09/23/2020] [Accepted: 10/02/2020] [Indexed: 01/21/2023] Open
Abstract
Objectives Cytomegalovirus (CMV)‐related encephalitis is a rare but potentially life‐threatening complication of CMV infection in immunocompromised patients. The high mortality rate is associated with deficient immune system reconstitution after hematopoietic stem cell transplant (HSCT) and poor bioavailability of antiviral drugs in cerebrospinal fluid (CSF). CMV‐related central nervous system (CNS) infection may occur with aspecific symptoms, without evidence of either blood viral load or magnetic resonance imaging (MRI) signs of encephalitis. Methods Here, we describe a 10‐year‐old girl who underwent an allogeneic HSCT and subsequently developed CMV encephalitis. Because of the absence of CMV antigen in the blood, the diagnosis of encephalitis was proposed only after a delay, following the onset of immune reconstitution inflammatory syndrome (IRIS). Two months of combined dual antiviral therapy with ganciclovir and foscarnet proved ineffective against CMV and caused significant bone marrow and renal toxicity. To avoid further toxicity, the girl was given daily treatment with CMV‐hyperimmune globulins alone. Results After three weeks, the CSF viral load dropped significantly and was undetectable within three more weeks. In the meantime, the renal impairment resolved, and there was a complete bone marrow recovery. Conclusion We suggest that this patient succeeded in achieving CMV CSF clearance with high dose of CMV‐hyperimmune globulin, given alone, because of the ability of immunoglobulins to penetrate the blood–brain barrier (BBB).
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Affiliation(s)
- Natalia Maximova
- Institute for Maternal and Child Health - IRCCS Burlo Garofolo Trieste Italy
| | | | | | - Davide Zanon
- Institute for Maternal and Child Health - IRCCS Burlo Garofolo Trieste Italy
| | - Alessandra Maestro
- Institute for Maternal and Child Health - IRCCS Burlo Garofolo Trieste Italy
| | - Egidio Barbi
- Institute for Maternal and Child Health - IRCCS Burlo Garofolo Trieste Italy.,University of Trieste Trieste Italy
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12
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Vinhaes CL, Sheikh V, Oliveira-de-Souza D, Wang J, Rupert A, Roby G, Arriaga MB, Fukutani KF, Sawe F, Shaffer D, Ananworanich J, Phanuphak N, Andrade BB, Sereti I. An Inflammatory Composite Score Predicts Mycobacterial Immune Reconstitution Inflammatory Syndrome in People with Advanced HIV: A Prospective International Cohort Study. J Infect Dis 2020; 223:1275-1283. [PMID: 32761193 DOI: 10.1093/infdis/jiaa484] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [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: 06/02/2020] [Accepted: 08/07/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Immune reconstitution inflammatory syndrome (IRIS) is a common cause of morbidity among people with human immunodeficiency virus (PWH) who initiate antiretroviral therapy (ART) with severe lymphopenia. Easily accessible tools that reliably predict emergence and elucidate pathogenesis of IRIS are needed to facilitate improved clinical management. METHODS Plasma levels of biomarkers were measured before ART initiation in a large multinational cohort of ART-naive PWH with severe immunosuppression (CD4+ count <100 cells/mm3) in United States, Kenya, and Thailand. We performed a series of multiparametric analyses of inflammatory and clinical biomarkers and developed a composite score merging relevant biomarkers for use in a prediction model. RESULTS We identified a distinct baseline inflammatory profile and changes in inflammatory networks among biomarkers in participants who subsequently developed mycobacterial or viral IRIS. We also developed a composite score incorporating biomarkers associated with IRIS (interleukin-6 [IL-6], IL-10, IL-27, sCD14, interferon-γ, tumor necrosis factor-α, hyaluronic acid, D-dimer, body mass index, and hemoglobin) that accurately predicted mycobacterial IRIS and death in this cohort. CONCLUSIONS Systemic inflammatory profiles in PWH with severe immunosuppression are predictive of IRIS. Composite scores for the prediction of mycobacterial IRIS and death could be useful for risk stratification in PWH and lymphopenia initiating ART. CLINICAL TRIALS REGISTRATION NCT00286767.
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Affiliation(s)
- Caian L Vinhaes
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research Initiative, Salvador, Brazil.,Curso de Medicina, Faculdade de Tecnologia e Ciências, Salvador, Brazil
| | - Virginia Sheikh
- National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Deivide Oliveira-de-Souza
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research Initiative, Salvador, Brazil.,Curso de Medicina, Faculdade de Tecnologia e Ciências, Salvador, Brazil
| | - Jing Wang
- National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Adam Rupert
- National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Gregg Roby
- National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - María B Arriaga
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research Initiative, Salvador, Brazil.,Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil
| | - Kiyoshi F Fukutani
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research Initiative, Salvador, Brazil
| | - Fred Sawe
- Kenya Medical Research Institute, Henry Jackson Foundation Medical Research International, Bethesda, Maryland, USA
| | - Doug Shaffer
- Kenya Medical Research Institute, Henry Jackson Foundation Medical Research International, Bethesda, Maryland, USA
| | - Jintanat Ananworanich
- South East Asia Research Collaboration with Hawaii, Henry M. Jackson Foundation for the Advancement of Military Medicine, United States Military HIV Research Program, Bethesda, Maryland, USA
| | | | - Bruno B Andrade
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research Initiative, Salvador, Brazil.,Curso de Medicina, Faculdade de Tecnologia e Ciências, Salvador, Brazil.,Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil.,Universidade Salvador, Laureate Universities, Salvador, Brazil.,Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Irini Sereti
- National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
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13
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Sereti I, Sheikh V, Shaffer D, Phanuphak N, Gabriel E, Wang J, Nason MC, Roby G, Ngeno H, Kirui F, Pau A, Mican JM, Rupert A, Bishop R, Agan B, Chomchey N, Teeratakulpisarn N, Tansuphaswadikul S, Langat D, Kosgei J, French M, Ananworanich J, Sawe F. Prospective International Study of Incidence and Predictors of Immune Reconstitution Inflammatory Syndrome and Death in People Living With Human Immunodeficiency Virus and Severe Lymphopenia. Clin Infect Dis 2020; 71:652-660. [PMID: 31504347 PMCID: PMC7384325 DOI: 10.1093/cid/ciz877] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [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: 05/03/2019] [Accepted: 09/03/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Patients living with human immunodeficiency virus (PLWH) with low CD4 counts are at high risk for immune reconstitution inflammatory syndrome (IRIS) and death at antiretroviral therapy (ART) initiation. METHODS We investigated the clinical impact of IRIS in PLWH and CD4 counts <100 cells/μL starting ART in an international, prospective study in the United States, Thailand, and Kenya. An independent review committee adjudicated IRIS events. We assessed associations between baseline biomarkers, IRIS, immune recovery at week 48, and death by week 48 with Cox models. RESULTS We enrolled 506 participants (39.3% were women). Median age was 37 years, and CD4 count was 29 cells/μL. Within 6 months of ART, 97 (19.2%) participants developed IRIS and 31 (6.5%) died. Participants with lower hemoglobin at baseline were at higher IRIS risk (hazard ratio [HR], 1.2; P = .004). IRIS was independently associated with increased risk of death after adjustment for known risk factors (HR, 3.2; P = .031). Being female (P = .004) and having a lower body mass index (BMI; P = .003), higher white blood cell count (P = .005), and higher D-dimer levels (P = .044) were also significantly associated with increased risk of death. Decision-tree analysis identified hemoglobin <8.5 g/dL as predictive of IRIS and C-reactive protein (CRP) >106 μg/mL and BMI <15.6 kg/m2 as predictive of death. CONCLUSIONS For PLWH with severe immunosuppression initiating ART, baseline low BMI and hemoglobin and high CRP and D-dimer levels may be clinically useful predictors of IRIS and death risk.
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Affiliation(s)
- Irini Sereti
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Virginia Sheikh
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Douglas Shaffer
- Walter Reed Army Institute of Research/US Army Medical Research Directorate–Africa, Nairobi, Kenya
- Walter Reed Army Institute of Research, US Military Human Immunodeficiency Virus Research Program, Silver Spring, Maryland, USA
| | - Nittaya Phanuphak
- South East Asia Research Collaboration with Hawaii, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Erin Gabriel
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Jing Wang
- Clinical Research Directorate/Clinical Monitoring Research Program, Leidos Biomedical Research, Inc, National Cancer Institute Campus at Frederick, Maryland, USA
| | - Martha C Nason
- Division of Clinical Research, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Gregg Roby
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Hellen Ngeno
- Walter Reed Army Institute of Research/US Army Medical Research Directorate–Africa, Nairobi, Kenya
| | - Fredrick Kirui
- Kenya Medical Research Institute/US Army Medical Research Directorate–Africa–Kenya/ Henry Jackson Foundation Medical Research International, Kericho Clinical Research Center, Kenya
| | - Alice Pau
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Joann M Mican
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Adam Rupert
- Applied and Developmental Research Directorate, AIDS Monitoring Laboratory, Leidos Biomedical Research, Inc, Frederick, Maryland, USA
| | - Rachel Bishop
- National Eye Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Brian Agan
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Nitiya Chomchey
- South East Asia Research Collaboration with Hawaii, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Nipat Teeratakulpisarn
- South East Asia Research Collaboration with Hawaii, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | | | - Deborah Langat
- Kenya Medical Research Institute/US Army Medical Research Directorate–Africa–Kenya/ Henry Jackson Foundation Medical Research International, Kericho Clinical Research Center, Kenya
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Josphat Kosgei
- Kenya Medical Research Institute/US Army Medical Research Directorate–Africa–Kenya/ Henry Jackson Foundation Medical Research International, Kericho Clinical Research Center, Kenya
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Martyn French
- University of Western Australia, Medical School and School of Biomedical Sciences, Nedlands, Australia
| | - Jintanat Ananworanich
- South East Asia Research Collaboration with Hawaii, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
- US Military Human Immunodeficiency Virus Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- Department of Global Health, Amsterdam Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Fredrick Sawe
- Kenya Medical Research Institute/US Army Medical Research Directorate–Africa–Kenya/ Henry Jackson Foundation Medical Research International, Kericho Clinical Research Center, Kenya
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
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14
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Gouel-Cheron A, Nason M, Rupert A, Sheikh V, Robby G, Fahle GA, Sereti I. Cardiovascular Biomarker Profile on Antiretroviral Therapy Is Not Influenced by History of an IRIS Event in People With HIV and Suppressed Viremia. Open Forum Infect Dis 2020; 7:ofaa017. [PMID: 32016127 DOI: 10.1093/ofid/ofaa017] [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: 10/28/2019] [Accepted: 01/09/2020] [Indexed: 11/13/2022] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) is characterized by release of proinflammatory cytokines and tissue inflammation occurring early after antiretroviral therapy (ART) initiation. The role of previous IRIS events in persistent chronic inflammation in people with HIV is currently unclear. In this retrospective analysis of 143 participants who maintained suppression of HIV viremia, we compared biomarkers related to inflammation, coagulation, and cardiovascular risk after 3 years on ART in participants with and without a history of IRIS. There was no evidence of higher levels of persistent chronic inflammation in people with HIV who had a history of an IRIS event. ClinicalTrials.gov Identifier . NCT00286767.
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Affiliation(s)
- Aurelie Gouel-Cheron
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, USA.,Département d'Anesthésie et Réanimation Chirurgicale, Université de Paris, Groupe Hospitalier Bichat Claude Bernard, Assistance Publique Hôpitaux de Paris, Paris, France.,Unit of Antibodies in Therapy and Pathology, Pasteur Institut, UMR INSERM, Paris, France
| | - Martha Nason
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, USA
| | - Adam Rupert
- Leidos Biomedical Research Inc., NCI Campus at Frederick, Frederick, Maryland, USA
| | - Virginia Sheikh
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Greg Robby
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Gary A Fahle
- Department of Laboratory Medicine, Clinical Center (CC), National Institutes of Health, Bethesda, Maryland, USA
| | - Irini Sereti
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
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15
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Simaniv TO, Ivanova MV, Bryukhov VV, Zakharova MN. [A case of subtentorial progressive multifocal leucoencephalopathy in a patient treated with natalizumab]. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:98-106. [PMID: 31156248 DOI: 10.17116/jnevro20191192298] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This paper presents a case report of subtentorial progressive multifocal leukoencephalopathy (PML) in a 26-year-old female patient treated with natalizumab. The evolution of clinical features, neuroimaging data and treatment as well as the development of immune reconstitution inflammatory syndrome (IRIS) are described. This case emphasizes the importance to keep accurately the risk management plan during natalizumab treatment. This includes performing MRI scans in order to detect changes typical for PML at the earliest (preclinical) stage in time.
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Affiliation(s)
- T O Simaniv
- Research Center of Neurology, Moscow, Russia
| | - M V Ivanova
- Research Center of Neurology, Moscow, Russia
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16
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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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Abstract
The Cryptococcus neoformans/Cryptococcus gattii species complex is a group of fungal pathogens with different phenotypic and genotypic diversity that cause disease in immunocompromised patients as well as in healthy individuals. The immune response resulting from the interaction between Cryptococcus and the host immune system is a key determinant of the disease outcome. The species C. neoformans causes the majority of human infections, and therefore almost all immunological studies focused on C. neoformans infections. Thus, this review presents current understanding on the role of adaptive immunity during C. neoformans infections both in humans and in animal models of disease.
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18
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Roussey JA, Olszewski MA, Osterholzer JJ. Immunoregulation in Fungal Diseases. Microorganisms 2016; 4:microorganisms4040047. [PMID: 27973396 PMCID: PMC5192530 DOI: 10.3390/microorganisms4040047] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [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: 11/04/2016] [Revised: 12/02/2016] [Accepted: 12/06/2016] [Indexed: 02/07/2023] Open
Abstract
This review addresses specific regulatory mechanisms involved in the host immune response to fungal organisms. We focus on key cells and regulatory pathways involved in these responses, including a brief overview of their broader function preceding a discussion of their specific relevance to fungal disease. Important cell types discussed include dendritic cells and regulatory T cells, with a focus on specific studies relating to their effects on immune responses to fungi. We highlight the interleukin-10, programmed cell death 1, and cytotoxic T lymphocyte-associated protein 4 signaling pathways and emphasize interrelationships between these pathways and the regulatory functions of dendritic cells and regulatory T cells. Throughout our discussion, we identify selected studies best illustrating the role of these cells and pathways in response to specific fungal pathogens to provide a contextual understanding of the tightly-controlled network of regulatory mechanisms critical to determining the outcome of exposure to fungal pathogens. Lastly, we discuss two unique phenomena relating to immunoregulation, protective tolerance and immune reactivation inflammatory syndrome. These two clinically-relevant conditions provide perspective as to the range of immunoregulatory mechanisms active in response to fungi.
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Affiliation(s)
- Jonathan A Roussey
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI 48109, USA.
- Pulmonary Section, Medical Service, VA Ann Arbor Health System, Ann Arbor, MI 48105, USA.
| | - Michal A Olszewski
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI 48109, USA.
- Pulmonary Section, Medical Service, VA Ann Arbor Health System, Ann Arbor, MI 48105, USA.
- Graduate Program in Immunology, University of Michigan Health System, Ann Arbor, MI 48109, USA.
| | - John J Osterholzer
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI 48109, USA.
- Pulmonary Section, Medical Service, VA Ann Arbor Health System, Ann Arbor, MI 48105, USA.
- Graduate Program in Immunology, University of Michigan Health System, Ann Arbor, MI 48109, USA.
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19
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de Regt MJA, Murk JL, Schneider-Hohendorf T, Wattjes MP, Hoepelman AIM, Arends JE. Progressive multifocal leukoencephalopathy and black fungus in a patient with rheumatoid arthritis without severe lymphocytopenia. JMM Case Rep 2016; 3:e005053. [PMID: 28348775 PMCID: PMC5330243 DOI: 10.1099/jmmcr.0.005053] [Citation(s) in RCA: 6] [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: 12/20/2015] [Accepted: 06/04/2016] [Indexed: 11/18/2022] Open
Abstract
Introduction: Progressive multifocal leukoencephalopathy (PML) is a rare demyelinating brain infection caused by JC polyomavirus (JCV), primarily seen in patients with severely compromised cellular immunity. Clinical presentation varies depending on the affected white matter. PML prognosis is variable and effective treatments are lacking. Case presentation: A 75-year-old Chinese woman with type 2 diabetes mellitus, chronic kidney disease and rheumatoid arthritis, treated with low-dose methotrexate and prednisolone for 2.5 years, developed a Pleurostomophora richardsiae infection of her left arm. After 6 months of treating this rare black fungus infection with voriconazole, surgery and immunosuppression discontinuation, she presented with progressive afebrile encephalopathy with right-sided hemiparesis. There were no signs of inflammation or metabolic abnormalities. Brain magnetic resonance imaging revealed diffuse frontal white matter lesions and a cerebrospinal fluid PCR confirmed PML due to JC virus. Severe lymphopenia was never present, and at PML diagnosis, CD4 and CD8 T-cell counts were 454 mm−3 and 277 mm−3. CD8 T-cells were able to respond to JCV VP1 peptide stimulation with TNFα secretion. Peripheral B-cell count was only 8 mm−3. Mirtazapine and Maraviroc were started, but unfortunately, she rapidly deteriorated and died 5 weeks after PML diagnosis. Conclusion: Although peripheral lymphocyte counts were never low and CD4 T-cell count was close to normal, the persistent black fungus infection was a hallmark of severely compromised cellular immunity. The unexpected extremely low absolute B-cell count might suggest a protective role for B-cells. The paradoxical, clinical PML onset months after immunosuppressive discontinuation suggests that it was only discovered in the context of an immune reconstitution inflammatory syndrome.
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Affiliation(s)
- Marieke J A de Regt
- Department of Internal Medicine and infectious Diseases, University Medical Centre Utrecht, the Netherlands
| | - Jean-Luc Murk
- Department of Medical Microbiology, University Medical Centre Utrecht , Utrecht , the Netherlands
| | | | - Mike P Wattjes
- Department of Radiology and Nuclear Medicine, VU University Medical Centre, Amsterdam, the Netherlands
| | - Andy I M Hoepelman
- Department of Internal Medicine and infectious Diseases, University Medical Centre Utrecht, the Netherlands
| | - Joop E Arends
- Department of Internal Medicine and infectious Diseases, University Medical Centre Utrecht, the Netherlands
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20
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Ravimohan S, Tamuhla N, Nfanyana K, Steenhoff AP, Letlhogile R, Frank I, MacGregor RR, Gross R, Weissman D, Bisson GP. Robust Reconstitution of Tuberculosis-Specific Polyfunctional CD4+ T-Cell Responses and Rising Systemic Interleukin 6 in Paradoxical Tuberculosis-Associated Immune Reconstitution Inflammatory Syndrome. Clin Infect Dis 2015; 62:795-803. [PMID: 26611774 DOI: 10.1093/cid/civ978] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [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: 09/27/2015] [Accepted: 11/17/2015] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The immunopathogenesis of paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) remains unclear. We determined the association between pathogen-specific T-cell responses and development of paradoxical TB-IRIS on antiretroviral therapy (ART). METHODS This study was nested within a prospective cohort study of HIV-infected patients with active pulmonary tuberculosis and baseline CD4 counts ≤125 cells/µL initiating ART. T-cell immune activation (CD38, HLA-DR, and PD-1 expression), phenotype, and polyfunctional pathogen-specific cellular immune responses prior to and 4 weeks after ART initiation were determined by flow cytometry. Patients with TB-IRIS were compared to non-IRIS controls using χ(2) and rank-sum tests and logistic regression. RESULTS TB-IRIS patients and controls had similar CD4 counts, levels of T-cell-associated immune activation, frequencies of T-cell memory subsets, and frequencies of interferon gamma (IFN-γ(+))/interleukin 2 (IL-2(+))/tumor necrosis factor alpha (TNF-α(+)) CD4(+) T-cells prior to ART initiation. After ART initiation, cellular immune activation and T-cell subsets also were similar in TB-IRIS patients and controls. In contrast, TB-IRIS patients had significantly greater early increases in the frequency of tuberculosis-specific polyfunctional IFN-γ(+)/IL-2(+)/TNF-α(+) CD4(+) T-cells on ART (P = .02); each quartile increase in the percentage of these cells was independently associated with a 2.8-fold increased risk of TB-IRIS (95% confidence interval, 1.1 to 7.5-fold). In a secondary analysis, patients with TB-IRIS had rapid, concomitant increases in tuberculosis-specific adaptive immune responses and interleukin 6 (IL-6) levels, whereas controls with similarly rapid increases in cellular immune function had IL-6 levels that tended to decrease on ART. CONCLUSIONS Rapid expansion of tuberculosis-specific polyfunctional CD4(+) T-cell responses, likely linked to increases in IL-6, is associated with development of paradoxical TB-IRIS.
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Affiliation(s)
- Shruthi Ravimohan
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Botswana-UPenn Partnership, Gaborone
| | | | | | - Andrew P Steenhoff
- Botswana-UPenn Partnership, Gaborone.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania.,Children's Hospital of Philadelphia
| | | | - Ian Frank
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Rob Roy MacGregor
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Robert Gross
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Botswana-UPenn Partnership, Gaborone.,Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Drew Weissman
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Botswana-UPenn Partnership, Gaborone
| | - Gregory P Bisson
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Botswana-UPenn Partnership, Gaborone.,Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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Gianella S, Redd AD, Grabowski MK, Tobian AAR, Serwadda D, Newell K, Patel EU, Kalibbala S, Ssebbowa P, Gray RH, Quinn TC, Reynolds SJ. Vaginal Cytomegalovirus Shedding Before and After Initiation of Antiretroviral Therapy in Rakai, Uganda. J Infect Dis 2015; 212:899-903. [PMID: 25743428 DOI: 10.1093/infdis/jiv135] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [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: 01/21/2015] [Accepted: 02/26/2015] [Indexed: 12/22/2022] Open
Abstract
Vaginal shedding of cytomegalovirus (CMV) DNA was determined longitudinally among 96 women coinfected with human immunodeficiency virus (HIV), herpes simplex virus 2, and CMV starting antiretroviral therapy (ART) during a placebo-controlled trial of HSV-2 suppression with acyclovir in Rakai, Uganda. Vaginal CMV was detected in 75 of 96 women (78.0%) and 379 of 1080 individual visits (35.1%). ART status, higher HIV RNA viral load before ART initiation, and younger age were significantly associated with increased frequency of CMV shedding (P < .01). Compared to pre-ART, CMV shedding peaked from month 2 to month 4 after ART initiation, suggesting possible immune reconstitution inflammatory syndrome. Further studies need to determine the clinical significance of asymptomatic CMV shedding.
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Affiliation(s)
- Sara Gianella
- Department of Infectious Disease, University of California San Diego, La Jolla
| | - Andrew D Redd
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda Department of Medicine, School of Medicine, Johns Hopkins University
| | - Mary K Grabowski
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health
| | - Aaron A R Tobian
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - David Serwadda
- Rakai Health Sciences Program, Entebbe Institute of Public Health, Makerere University, Kampala, Uganda
| | - Kevin Newell
- Clinical Research Directorate/Clinical Monitoring Research Program, SAIC-Frederick, Inc, Frederick National Laboratory for Cancer Research, Maryland
| | - Eshan U Patel
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda
| | | | | | - Ronald H Gray
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health Rakai Health Sciences Program, Entebbe
| | - Thomas C Quinn
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda Department of Medicine, School of Medicine, Johns Hopkins University
| | - Steven J Reynolds
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda Department of Medicine, School of Medicine, Johns Hopkins University Rakai Health Sciences Program, Entebbe
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Tobian AAR, Grabowski MK, Serwadda D, Newell K, Ssebbowa P, Franco V, Nalugoda F, Wawer MJ, Gray RH, Quinn TC, Reynolds SJ. Reactivation of herpes simplex virus type 2 after initiation of antiretroviral therapy. J Infect Dis 2013; 208:839-46. [PMID: 23812240 DOI: 10.1093/infdis/jit252] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [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: 11/14/2022] Open
Abstract
BACKGROUND The association between initiation of antiretroviral therapy (ART) for human immunodeficiency virus (HIV) infection and possible herpes simplex virus type 2 (HSV-2) shedding and genital ulcer disease (GUD) has not been evaluated. METHODS GUD and vaginal HSV-2 shedding were evaluated among women coinfected with HIV and HSV-2 (n = 440 for GUD and n = 96 for HSV-2 shedding) who began ART while enrolled in a placebo-controlled trial of HSV-2 suppression with acyclovir in Rakai, Uganda. Monthly vaginal swabs were tested for HSV-2 shedding, using a real-time quantitative polymerase chain reaction assay. Prevalence risk ratios (PRRs) of GUD were estimated using log binomial regression. Random effects logistic regression was used to estimate odds ratios (ORs) of HSV-2 shedding. RESULTS Compared with pre-ART values, GUD prevalence increased significantly within the first 3 months after ART initiation (adjusted PRR, 1.94; 95% confidence interval [CI], 1.04-3.62) and returned to baseline after 6 months of ART (adjusted PRR, 0.80; 95% CI, .35-1.80). Detection of HSV-2 shedding was highest in the first 3 months after ART initiation (adjusted OR, 2.58; 95% CI, 1.48-4.49). HSV-2 shedding was significantly less common among women receiving acyclovir (adjusted OR, 0.13; 95% CI, .04-.41). CONCLUSIONS The prevalence of HSV-2 shedding and GUD increased significantly after ART initiation, possibly because of immune reconstitution inflammatory syndrome. Acyclovir significantly reduced both GUD and HSV-2 shedding and should be considered to mitigate these effects following ART initiation.
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Affiliation(s)
- Aaron A R Tobian
- Department of Pathology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21287, USA.
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Meteyer CU, Barber D, Mandl JN. Pathology in euthermic bats with white nose syndrome suggests a natural manifestation of immune reconstitution inflammatory syndrome. Virulence 2012; 3:583-8. [PMID: 23154286 PMCID: PMC3545935 DOI: 10.4161/viru.22330] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [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] [Indexed: 11/19/2022] Open
Abstract
White nose syndrome, caused by Geomyces destructans, has killed more than 5 million cave hibernating bats in eastern North America. During hibernation, the lack of inflammatory cell recruitment at the site of fungal infection and erosion is consistent with a temperature-induced inhibition of immune cell trafficking. This immune suppression allows G. destructans to colonize and erode the skin of wings, ears and muzzle of bat hosts unchecked. Yet, paradoxically, within weeks of emergence from hibernation an intense neutrophilic inflammatory response to G. destructans is generated, causing severe pathology that can contribute to death. We hypothesize that the sudden reversal of immune suppression in bats upon the return to euthermia leads to a form of immune reconstitution inflammatory syndrome (IRIS). IRIS was first described in HIV-infected humans with low helper T lymphocyte counts and bacterial or fungal opportunistic infections. IRIS is a paradoxical and rapid worsening of symptoms in immune compromised humans upon restoration of immunity in the face of an ongoing infectious process. In humans with HIV, the restoration of adaptive immunity following suppression of HIV replication with anti-retroviral therapy (ART) can trigger severe immune-mediated tissue damage that can result in death. We propose that the sudden restoration of immune responses in bats infected with G. destructans results in an IRIS-like dysregulated immune response that causes the post-emergent pathology.
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Affiliation(s)
- Carol U Meteyer
- National Wildlife Health Center, US Geological Survey, Madison, WI, USA
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