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Machava P, Joaquim W, Borrell J, Richardson S, Cassia U, Sidat M, Maieca A, Massitela C, Quelhas Y, Mucuila C, Elias B, da Rocha M, Schaaf HS, Buck WC. Severe BCG immune reconstitution inflammatory syndrome lymphadenitis successfully managed with pre-antiretroviral counseling and a non-surgical approach: a case report. AIDS Res Ther 2024; 21:25. [PMID: 38678293 PMCID: PMC11056047 DOI: 10.1186/s12981-024-00614-7] [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: 02/23/2024] [Accepted: 04/09/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Bacillus Calmette-Guérin (BCG) reactions are the most common cause of immune reconstitution inflammatory syndrome (IRIS) in HIV-positive infants who initiate antiretroviral therapy (ART). There is limited evidence regarding the incidence of BCG-IRIS; however, reports from outpatient cohorts have estimated that 6-9% of infants who initiated ART developed some form of BCG-IRIS within the first 6 months. Various treatment approaches for infants with BCG-IRIS have been reported, but there is currently no widely accepted standard-of-care. CASE PRESENTATION A 5-month-old male HIV-exposed infant BCG vaccinated at birth was admitted for refractory oral candidiasis, moderate anemia, and moderate acute malnutrition. He had a HIV DNA-PCR collected at one month of age, but the family never received the results. He was diagnosed with HIV during hospitalization with a point-of-care nucleic acid test and had severe immune suppression with a CD4 of 955 cells/µL (15%) with clinical stage III disease. During pre-ART counseling, the mother was educated on the signs and symptoms of BCG-IRIS and the importance of seeking follow-up care and remaining adherent to ART if symptoms arose. Three weeks after ART initiation, he was readmitted with intermittent subjective fevers, right axillary lymphadenopathy, and an ulcerated papule over the right deltoid region. He was subsequently discharged home with a diagnosis of local BCG-IRIS lymphadenitis. At six weeks post-ART initiation, he returned with suppurative lymphadenitis of the right axillary region that had completely eviscerated through the skin without signs of disseminated BCG disease. He was then started on an outpatient regimen of topical isoniazid, silver nitrate, and oral prednisolone. Throughout this time, the mother maintained good ART adherence despite this complication. After 2.5 months of ART and one month of specific treatment for the lymphadenitis, he had marked mass reduction, improved adenopathy, increased CD4 count, correction of anemia, and resolution of his acute malnutrition. He completely recovered and was symptom free two months after initial treatment without surgical intervention. CONCLUSIONS This case details the successful management of severe suppurative BCG-IRIS with a non-surgical approach and underlines the importance of pre-ART counseling on BCG-IRIS for caregivers, particularly for infants who initiate ART with advanced HIV.
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Affiliation(s)
| | - Winete Joaquim
- Universidade Eduardo Mondlane Faculdade de Medicina, Maputo, Mozambique.
| | - Joseph Borrell
- University of California Los Angeles David Geffen School of Medicine, Los Angeles, USA
| | - Shannon Richardson
- University of California Los Angeles David Geffen School of Medicine, Los Angeles, USA
| | - Uneisse Cassia
- Universidade Eduardo Mondlane Faculdade de Medicina, Maputo, Mozambique
| | - Muhammad Sidat
- Universidade Eduardo Mondlane Faculdade de Medicina, Maputo, Mozambique
| | - Alice Maieca
- Universidade Eduardo Mondlane Faculdade de Medicina, Maputo, Mozambique
| | - Cláudia Massitela
- Universidade Eduardo Mondlane Faculdade de Medicina, Maputo, Mozambique
| | | | | | | | | | - H Simon Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - W Chris Buck
- Hospital Central de Maputo, Maputo, Mozambique
- University of California Los Angeles David Geffen School of Medicine, Los Angeles, USA
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2
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Musubire A, Kagimu E, Mugabi T, Meya DB, Boulware DR, Bahr NC. Complex Decisions in HIV-Related Cryptococcosis: Addressing Second Episodes of Cryptococcal Meningitis. Curr HIV/AIDS Rep 2024; 21:75-85. [PMID: 38400871 PMCID: PMC11016006 DOI: 10.1007/s11904-024-00691-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2024] [Indexed: 02/26/2024]
Abstract
PURPOSE OF REVIEW This review highlights the difficulties in diagnosing and treating persons with a prior history of cryptococcal meningitis who improve but suffer from a recurrence of symptoms. This scenario is well known to those who frequently care for patients with cryptococcal meningitis but is not well understood. We highlight major gaps in knowledge. RECENT FINDINGS We recently summarized our experience with 28 persons with paradoxical immune reconstitution inflammatory syndrome (IRIS) and 81 persons with microbiological relapse. CD4 count and cerebrospinal fluid white blood cell count were higher in IRIS than relapse but neither was reliable enough to routinely differentiate these conditions. Second-episode cryptococcal meningitis remains a difficult clinical scenario as cryptococcal antigen, while excellent for initial diagnosis has no value in differentiating relapse of infection from other causes of recurrent symptoms. Updated research definitions are proposed and rapid, accurate diagnostic tests are urgently needed.
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Affiliation(s)
- Abdu Musubire
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Enock Kagimu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Timothy Mugabi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, 66160 KS, USA.
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3
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Ramírez-Marín HA, Domínguez-Cherit JG. [Translated article] Virus Reactivation With Eosinophilia and Systemic Symptoms: An Imitator of Immune Reconstitution Inflammatory Syndrome With an Excellent Clinical Response to Valganciclovir. Actas Dermosifiliogr 2023; 114:T841-T843. [PMID: 37506834 DOI: 10.1016/j.ad.2022.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 04/13/2022] [Indexed: 07/30/2023] Open
Affiliation(s)
- H A Ramírez-Marín
- Dermatology Department, Weill Cornell Medical College, New York, NY, USA; Dermatology Department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - J G Domínguez-Cherit
- Dermatology Department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico.
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4
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Lee S, Yi NJ, Kwak N, Kim H, Hong SY, Lee JM, Hong SK, Choi Y, Lee KW, Suh KS. Immune Reconstitution Inflammatory Syndrome and Drug-Induced Liver Injury During Treatment of Disseminated Tuberculosis in a Liver Transplant Recipient: A Case Report. Transplant Proc 2023; 55:1972-1974. [PMID: 37468353 DOI: 10.1016/j.transproceed.2023.06.007] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 06/23/2023] [Indexed: 07/21/2023]
Abstract
Studies have shown that tuberculosis (TB) incidence is 20 to 70 times higher in solid organ transplantation recipients. Immunosuppression makes transplant recipients more vulnerable to infection and can interfere with the treatment. Our case report describes a patient who experienced immune reconstitution inflammatory syndrome (IRIS) and drug-induced liver injury (DILI) related to TB medications for disseminated pulmonary and hepatic TB. In addition to anti-TB medication, the patient received a high-dose steroid for IRIS and a change of anti-TB medication to a secondary regimen for DILI. This case illustrates various responses to anti-TB treatment in a liver transplant recipient and the necessity of closely monitoring immune suppression and liver function.
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Affiliation(s)
- Sola Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Nakwon Kwak
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Haeryoung Kim
- Department of Pathology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Su Young Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jeong-Moo Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Suk Kyun Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - YoungRok Choi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
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Ramírez-Marín HA, Domínguez-Cherit JG. Virus Reactivation With Eosinophilia and Systemic Symptoms: An Imitator of Immune Reconstitution Inflammatory Syndrome With an Excellent Clinical Response to Valganciclovir. Actas Dermosifiliogr 2023; 114:841-843. [PMID: 36567028 DOI: 10.1016/j.ad.2022.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 04/08/2022] [Accepted: 04/13/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
- H A Ramírez-Marín
- Dermatology Department, Weill Cornell Medical College, Nueva York, Estados Unidos
| | - J G Domínguez-Cherit
- Dermatology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, México.
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6
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Schwartzmann Y, Vaknin-Dembinsky A, Gomori JM, Elinav H, Berkun Y, Levin N, Ekstein D, Magadle J, Gotkine M. Tofacitinib-induced progressive multifocal leukoencephalopathy-immune reconstitution inflammatory syndrome. Neurol Sci 2023; 44:3737-3739. [PMID: 37306796 DOI: 10.1007/s10072-023-06897-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 06/07/2023] [Indexed: 06/13/2023]
Affiliation(s)
- Yoel Schwartzmann
- Department of Neurology, Hadassah Medical Center, Jerusalem, Israel.
| | - Adi Vaknin-Dembinsky
- Department of Neurology, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - John Moshe Gomori
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
- Department of Neuroradiology, Hadassah Medical Center, Jerusalem, Israel
| | - Hila Elinav
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
- Department of Clinical Microbiology and Infectious Diseases, Hadassah Medical Center, Jerusalem, Israel
| | - Yackov Berkun
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
- Department of Pediatrics, Hadassah Medical Center, Jerusalem, Israel
| | - Netta Levin
- Department of Neurology, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Dana Ekstein
- Department of Neurology, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Jad Magadle
- Department of Neurology, Hadassah Medical Center, Jerusalem, Israel
| | - Marc Gotkine
- Department of Neurology, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
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Hashiba T, Sugahara M, Ota Y, Kaseda K, Kashiwagi Y, Nakamura M, Shinohara T, Ikeda M, Okugawa S, Sugimoto K, Sasaki K, Hamasaki Y, Yamada D, Kume H, Moriya K, Nangaku M. Paralytic Ileus during Treatment of Pulmonary and Renal Tuberculosis in a Non-Human Immunodeficiency Virus Patient: An Unusual Presentation of Tuberculosis-immune Reconstitution Inflammatory Syndrome. Intern Med 2023; 62:2559-2564. [PMID: 36642517 PMCID: PMC10518560 DOI: 10.2169/internalmedicine.0898-22] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 11/29/2022] [Indexed: 01/15/2023] Open
Abstract
Paralytic ileus as tuberculosis-immune reconstitution inflammatory syndrome (TB-IRIS) is extremely rare. We herein report a 44-year-old man with pulmonary and renal tuberculosis who developed paralytic ileus 14 days after starting antituberculosis therapy (ATT) despite an initial favorable response to ATT. Paralytic ileus was successfully managed with conservative care. He initially required hemodialysis because of obstructive uropathy due to renal tuberculosis, but he was able to withdraw from dialysis after placement of ureteral stents. TB-IRIS can affect organs other than the original sites of tuberculosis, and the combined use of steroids may be effective for its prevention and treatment.
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Affiliation(s)
- Toyohiro Hashiba
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital, Japan
| | - Mai Sugahara
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital, Japan
| | - Yui Ota
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital, Japan
| | - Ken Kaseda
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital, Japan
| | - Yusuke Kashiwagi
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital, Japan
| | - Motonobu Nakamura
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital, Japan
| | - Takayuki Shinohara
- Department of Infectious Diseases, the University of Tokyo Hospital, Japan
| | - Mahoko Ikeda
- Department of Infectious Diseases, the University of Tokyo Hospital, Japan
| | - Shu Okugawa
- Department of Infectious Diseases, the University of Tokyo Hospital, Japan
| | - Kazuma Sugimoto
- Department of Urology, the University of Tokyo Hospital, Japan
| | - Kenichi Sasaki
- Department of Urology, the University of Tokyo Hospital, Japan
| | - Yoshifumi Hamasaki
- Department of Hemodialysis & Apheresis, the University of Tokyo Hospital, Japan
| | - Daisuke Yamada
- Department of Urology, the University of Tokyo Hospital, Japan
- Department of Hemodialysis & Apheresis, the University of Tokyo Hospital, Japan
| | - Haruki Kume
- Department of Urology, the University of Tokyo Hospital, Japan
| | - Kyoji Moriya
- Department of Infectious Diseases, the University of Tokyo Hospital, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital, Japan
- Department of Hemodialysis & Apheresis, the University of Tokyo Hospital, Japan
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8
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Tirlangi P, Challa HPR, Keithi-Reddy SR, Koduri VKC, Reddy RS, Arumilli MN, Reddy LSK, Senapathy G. Reversal of uniocular blindness with corticosteroids in a solid organ transplant recipient with cryptococcal meningitis and immune reconstitution syndrome (IRIS): A case report. J Mycol Med 2023; 33:101406. [PMID: 37229913 DOI: 10.1016/j.mycmed.2023.101406] [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: 02/09/2023] [Revised: 04/07/2023] [Accepted: 05/09/2023] [Indexed: 05/27/2023]
Abstract
Cryptococcal meningitis is a life-threatening infection commonly seen in patients with advanced HIV infection and solid organ transplant recipients. We report a case of cryptococcal meningitis with immune reconstitution syndrome (IRIS) who presented to us with a headache and complete loss of vision in the left eye. He was managed with antifungals and a short course of steroids, and he regained vision completely. In the hospital, he developed complications including tacrolimus toxicity, fluconazole-induced QT prolongation, and flucytosine-induced thrombocytopenia. Our case demonstrates the importance of a multidisciplinary approach in the management of complex cases like cryptococcal meningitis in solid organ transplant recipients.
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Affiliation(s)
- Praveen Tirlangi
- Department of Infectious Diseases AIG Hospitals, Gachibowli, Hyderabad 500032, India
| | | | - Sai Ram Keithi-Reddy
- Department of Nephrology and Renal Transplant, AIG Hospitals, Tower A, 1st floor, Gachibowli, Hyderabad 500032, India.
| | | | - R Sujith Reddy
- Department of Nephrology and Renal Transplant, AIG Hospitals, Tower A, 1st floor, Gachibowli, Hyderabad 500032, India
| | - Murthy Nln Arumilli
- Department of Critical Care, AIG Hospitals, Gachibowli, Hyderabad 500032, India
| | - L Siva Kumar Reddy
- Department of Critical Care, AIG Hospitals, Gachibowli, Hyderabad 500032, India
| | - Gayatri Senapathy
- Department of Radiology, AIG Hospitals, Gachibowli, Hyderabad 500032, India
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9
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Lisco A, Lange C, Manion M, Kuriakose S, Dewar R, Gorelick RJ, Huik K, Yu Q, Hammoud DA, Smith BR, Muranski P, Rehm C, Sherman BT, Sykes C, Lindo N, Ye P, Bricker KM, Keele BF, Fennessey CM, Maldarelli F, Sereti I. Immune reconstitution inflammatory syndrome drives emergence of HIV drug resistance from multiple anatomic compartments in a person living with HIV. Nat Med 2023; 29:1364-1369. [PMID: 37322122 PMCID: PMC10494392 DOI: 10.1038/s41591-023-02387-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 01/25/2022] [Accepted: 05/05/2023] [Indexed: 06/17/2023]
Abstract
Reservoirs of HIV maintained in anatomic compartments during antiretroviral therapy prevent HIV eradication. However, mechanisms driving their persistence and interventions to control them remain elusive. Here we report the presence of an inducible HIV reservoir within antigen-specific CD4+T cells in the central nervous system of a 59-year-old male with progressive multifocal leukoencephalopathy immune reconstitution inflammatory syndrome (PML-IRIS). HIV production during PML-IRIS was suppressed by modulating inflammation with corticosteroids; selection of HIV drug resistance caused subsequent breakthrough viremia. Therefore, inflammation can influence the composition, distribution and induction of HIV reservoirs, warranting it as a key consideration for developing effective HIV remission strategies.
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Affiliation(s)
- Andrea Lisco
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Camille Lange
- Clinical Retrovirology Section, HIV Dynamics and Replication Program National Cancer Institute, National Institutes of Health, Frederick, MD, USA.
- Military HIV Research Program, Walter Reed Army Institute of Research, Henry M. Jackson Foundation for the Advancement of Military Medicine, Silver Spring, MD, USA.
| | - Maura Manion
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Safia Kuriakose
- Clinical Research Directorate, Frederick National Laboratory for Cancer Research, Bethesda, MD, USA
| | - Robin Dewar
- Virus Isolation and Serology Laboratory, Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Robert J Gorelick
- AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Kristi Huik
- Clinical Retrovirology Section, HIV Dynamics and Replication Program National Cancer Institute, National Institutes of Health, Frederick, MD, USA
| | - Quan Yu
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Dima A Hammoud
- Center for Infectious Disease Imaging, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Bryan R Smith
- Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Pawel Muranski
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Catherine Rehm
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Brad T Sherman
- Laboratory of Human Retrovirology and Immunoinformatics, Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Craig Sykes
- Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Natalie Lindo
- Clinical Retrovirology Section, HIV Dynamics and Replication Program National Cancer Institute, National Institutes of Health, Frederick, MD, USA
| | - Peiying Ye
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Katherine M Bricker
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Brandon F Keele
- AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Christine M Fennessey
- AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Frank Maldarelli
- Clinical Retrovirology Section, HIV Dynamics and Replication Program National Cancer Institute, National Institutes of Health, Frederick, MD, USA.
| | - Irini Sereti
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA.
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Qu C, Xu N, Niu D, Wen S, Yang H, Wang S, Wang G. Case Report: Suspected Case of Brucella-Associated Immune Reconstitution Inflammatory Syndrome. Front Immunol 2022; 13:923341. [PMID: 35935931 PMCID: PMC9353035 DOI: 10.3389/fimmu.2022.923341] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/24/2022] [Indexed: 11/22/2022] Open
Abstract
Human brucellosis is one of the most prevalent zoonoses. There are many similarities between the pathogenesis of Mycobacterium tuberculosis (MTB) infection and that of brucellosis. Immune reconstitution inflammatory syndrome (IRIS) may occur during the treatment of MTB infection, but it has not been reported in brucellosis cases thus far. We report the case of a 40-year-old male whose condition initially improved after adequate anti-Brucella therapy. However, 3 weeks later, the patient presented with exacerbation of symptoms and development of a paravertebral abscess. After exclusion of other possible causes of clinical deterioration, immune reconstitution inflammatory syndrome (IRIS) with brucellosis was presumed. After supplementation with anti-Brucella treatment with corticosteroids, the abscess disappeared, and the symptoms completely resolved. Our case suggests that it is necessary to be aware of the possible occurrence of IRIS in patients with brucellosis in clinical practice.
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Affiliation(s)
- Chunmei Qu
- Department of Infectious Disease, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Nannan Xu
- Department of Infectious Disease, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Dehong Niu
- Department of Oncology, the Fifth People’s Hospital of Jinan, Jinan, China
| | - Sai Wen
- Department of Infectious Disease, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Hui Yang
- Department of Infectious Disease, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Shanshan Wang
- Department of Infectious Disease, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Gang Wang
- Department of Infectious Disease, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- *Correspondence: Gang Wang,
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11
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Xerri T, Borg J, Casha R, Fsadni C. Complexity of Mycobacterium avium complex immune reconstitution inflammatory syndrome (MAC-IRIS) in a patient with HIV. BMJ Case Rep 2021; 14:e241813. [PMID: 34479876 PMCID: PMC8420731 DOI: 10.1136/bcr-2021-241813] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2021] [Indexed: 01/08/2023] Open
Abstract
We report a case of Mycobacterium avium complex immune reconstitution inflammatory syndrome (MAC-IRIS) in a patient with HIV positive. Initial presentation was that of a purpuric purple macular rash in-keeping with Kaposi sarcoma as an AIDS defining illness. Three weeks following the initiation of antiretroviral treatment (ART) she developed chest pain, dry cough and fever. A diagnosis of MAC was made through imaging and sputum cultures and appropriate treatment was initiated. Despite adequate management with evidence of good immunological and virological response, the patient represented with persistent symptoms. Repeat CT of the chest confirmed worsening lymphadenopathy with necrosis. Given these findings, a diagnosis of MAC-IRIS was made with resolution of fever after corticosteroids were initiated. This case highlights the importance of considering MAC as a cause of IRIS in severely immunosuppressed patients with HIV.
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Affiliation(s)
- Thelma Xerri
- Infectious Diseases Unit, Mater Dei Hospital, Msida, Malta
| | - Janice Borg
- Department of Medicine, Mater Dei Hospital, Msida, Malta
| | - Ramon Casha
- Infectious Diseases Unit, Mater Dei Hospital, Msida, Malta
| | - Claudia Fsadni
- Infectious Diseases Unit, Mater Dei Hospital, Msida, Malta
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12
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Sindgikar SP, Narayanaswamy B, Alexander LM, Kanavu R. Paradoxical immune reconstitution inflammatory syndrome in neurotuberculosis. BMJ Case Rep 2021; 14:e243739. [PMID: 34376417 PMCID: PMC8356154 DOI: 10.1136/bcr-2021-243739] [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] [Accepted: 07/21/2021] [Indexed: 11/03/2022] Open
Abstract
Tuberculosis (TB) remains the most common infection in developing countries and India contributes the maximum number of cases to the global burden. Primary healthcare physicians across the country face major challenges in diagnosis and treatment of childhood TB. In this context, clinical cases of paradoxical responses to antitubercular therapy seem to be under-reported. We report a case of tubercular meningitis in an adolescent girl who belonged to a remote village. She developed a paradoxical immune response to TB while on anti-TB treatment (ATT). She presented with raised intracranial tension and neurological deficits during the continuation phase of ATT after stopping corticosteroids. The ring-enhancing lesions of tuberculomas in the brain and spine characterised the diagnosis of paradoxical response to TB. Brain biopsy suggested necrotising granulomatous disease and was negative for S100 and CD1a marker, ruling out active TB. Retreatment with a prolonged course of steroids and ATT resulted in the clinical and radiological recovery, though some motor and visual deficits persisted. Clinical risk factors and socioeconomic factors also contributed to the present state of the child.
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Affiliation(s)
- Seema Pavaman Sindgikar
- Pediatric, KS Hegde Medical Academy (KSHEMA), NITTE (Deeemed to be Univeristy), Mangalore, Karntaka, India
| | - Bindu Narayanaswamy
- Pediatric, KS Hegde Medical Academy (KSHEMA), NITTE (Deeemed to be Univeristy), Mangalore, Karntaka, India
| | - Lobo Manuel Alexander
- Neurology, KS Hegde Medical Academy (KSHEMA), NITTE (Deemed to be Univeristy), Mangalore, Karnataka, India
| | - Ramkishore Kanavu
- Radiology, KS Hegde Medical Academy (KSHEMA), NITTE (Deemed to be Univeristy), Mangalore, Karnataka, India
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13
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Wang Y, Lin X, Li Y, Wen Y. Multiple small bowel perforations due to cytomegalovirus related immune reconstitution inflammatory syndrome in an HIV patient: A case report. Medicine (Baltimore) 2021; 100:e26605. [PMID: 34260544 PMCID: PMC8284711 DOI: 10.1097/md.0000000000026605] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 06/22/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE The presentation of multiple intestinal perforations is a severe complication of enteric cytomegalovirus (CMV) infection, sometimes associated with immune reconstitution inflammatory syndrome (IRIS) after the initiation of antiretroviral therapy (ART) in patients with human immunodeficiency virus (HIV). Here we reported a rare case of a patient with HIV infection who developed multiple perforations in the small bowel shortly after ART initiation without any prodromal gastrointestinal symptoms. We also reviewed the literature of reported cases to clarify their clinical characteristics for early diagnosis and rapid intervention. PATIENT CONCERNS A patient with HIV presented with fever after 16 days of ART initiation and was admitted to our hospital. He was treated with intravenous ganciclovir due to persistent CMV viremia. The fever resolved 10 days later. However, he reported persistent left lower abdominal pain. DIAGNOSES The patient was diagnosed with multiple small bowel perforations, CMV-related IRIS, and acquired immune deficiency syndrome. An upright abdominal x-ray in a tertiary level hospital revealed bilateral moderate intraperitoneal free air. We performed a pathological examination and metagenomic next-generation sequencing. CMV enteritis was confirmed by immunohistochemical staining and other opportunistic infections were excluded by metagenomic next-generation sequencing. INTERVENTIONS The patient was treated with intravenous ganciclovir and 24 hours later, the patient underwent exploratory laparotomy. Partial resection and surgical repair of the small intestine were performed. OUTCOMES The patient ultimately died from intestinal obstruction and septic shock 55 days after surgery. LESSONS Perforations due to CMV-related IRIS are very rare, and usually appear shortly after ART initiation. Most cases lack the prodromal symptoms of abdominal pain and diarrhea. Intestinal perforations are lethal, and early detection and surgical treatment are lifesaving.
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Affiliation(s)
- Yanli Wang
- Infectious Diseases Department, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Xuyong Lin
- Pathology Department, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Yuji Li
- Gastrointestinal Surgery, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Ying Wen
- Infectious Diseases Department, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
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14
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Nabeya D, Kinjo T, Yamaniha K, Yamazato S, Tome R, Miyagi K, Nakamura H, Kinjo T, Haranaga S, Higa F, Fujita J. Use of steroids to treat anti-tumor necrosis factor α induced tuberculosis-associated immune reconstitution inflammatory syndrome: Case report and literature review. Medicine (Baltimore) 2020; 99:e22076. [PMID: 33120729 PMCID: PMC7581145 DOI: 10.1097/md.0000000000022076] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Individuals with tuberculosis (TB) who are being treated with anti-tumor necrosis factor α (anti-TNFα) for coexisting conditions may experience unexpected exacerbations of TB after the initiation of antituberculous therapy, so-called anti-TNFα-induced TB-immune reconstitution inflammatory syndrome (anti-TNFα-induced TB-IRIS). Anti-TNFα-induced TB-IRIS is often treated empirically with corticosteroids; however, the evidence of the effectiveness of corticosteroids is lacking and the management can be a challenge. PATIENT CONCERNS A 32-year-old man on long-term infliximab therapy for Crohn disease visited a clinic complaining of persistent fever and cough that had started 1 week previously. His most recent infliximab injection had been administered 14 days before the visit. A chest X-ray revealed a left pleural effusion, and he was admitted to a local hospital. DIAGNOSIS A chest computed tomography (CT) scan revealed miliary pulmonary nodules; acid-fast bacilli were found in a sputum smear and a urine sediment sample; and polymerase chain reaction confirmed the presence of Mycobacterium tuberculosis in both his sputum and the pleural effusion. He was diagnosed with miliary TB. INTERVENTIONS Antituberculous therapy was started and he was transferred to our hospital for further management. His symptoms initially improved after the initiation of antituberculous therapy, but 2 weeks later, his symptoms recurred and shadows on chest X-ray worsened. A repeat chest CT scan revealed enlarged miliary pulmonary nodules, extensive ground-glass opacities, and an increased volume of his pleural effusion. This paradoxical exacerbation was diagnosed as TB-IRIS associated with infliximab. A moderate-dose of systemic corticosteroid was initiated [prednisolone 25 mg/day (0.5 mg/kg/day)]. OUTCOMES After starting corticosteroid treatment, his radiological findings improved immediately, and his fever and cough disappeared within a few days. After discharge, prednisolone was tapered off over the course of 10 weeks, and he completed a 9-month course of antituberculous therapy uneventfully. He had not restarted infliximab at his most recent follow-up 14 months later. CONCLUSION We successfully managed a patient with anti-TNFα-induced TB-IRIS using moderate-dose corticosteroids. Due to the limited evidence currently available, physicians should consider the necessity, dosage, and duration of corticosteroids for each case of anti-TNFα-induced TB-IRIS on an individual patient-by-patient basis.
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Affiliation(s)
- Daijiro Nabeya
- Department of Infectious, Respiratory, and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus
- Department of Respiratory Medicine, Okinawa Chubu Hospital
| | - Takeshi Kinjo
- Department of Infectious, Respiratory, and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus
| | - Kazutaka Yamaniha
- Department of Infectious, Respiratory, and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus
| | - Shoshin Yamazato
- Department of Infectious, Respiratory, and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus
| | - Reo Tome
- Department of Infectious, Respiratory, and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus
| | - Kazuya Miyagi
- Department of Infectious, Respiratory, and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus
| | - Hideta Nakamura
- Department of Infectious, Respiratory, and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus
| | - Tetsu Kinjo
- Department of Infectious, Respiratory, and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus
| | - Shusaku Haranaga
- Department of Infectious, Respiratory, and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus
| | - Futoshi Higa
- Department of Respiratory Medicine, National Hospital Organization Okinawa National Hospital, Okinawa, Japan
| | - Jiro Fujita
- Department of Infectious, Respiratory, and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus
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15
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Kalinoski T, Malenfant J, Yim C, Jeng A. Case Report: A Case of Severe Cryptococcal Immune Reconstitution Inflammatory Syndrome Presenting with Brain and Intradural Abscesses in an HIV Patient. Am J Trop Med Hyg 2020; 103:713-718. [PMID: 32342852 PMCID: PMC7410480 DOI: 10.4269/ajtmh.20-0028] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 03/23/2020] [Indexed: 11/07/2022] Open
Abstract
Clinical worsening or new manifestation of cryptococcal disease following initiation of anti-retroviral therapy (ART) in an HIV patient is a hallmark of cryptococcal immune reconstitution inflammatory syndrome (C-IRIS). However, it can be difficult to distinguish IRIS from worsening or new infection. Here, we present a case of severe C-IRIS involving multiple cerebellar, spinal, and intradural abscesses and spinal arachnoiditis 7 months after ART initiation in an AIDS patient with uncertain prior ART compliance. He had multiple prior episodes of cryptococcal meningitis with complications necessitating ventriculoperitoneal shunt placement and was on suppressive fluconazole when he developed worsening brain manifestations. He received empiric anti-cryptococcal re-induction without improvement. All cerebrospinal fluid cultures remained sterile, with negative Cryptococcus PCR testing, and his condition continued to worsen prior to corticosteroid initiation. Ultimately, C-IRIS was diagnosed by brain biopsy. This case demonstrates an extreme in severity of C-IRIS and in the timeline of presentation after ART initiation.
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Affiliation(s)
- Thomas Kalinoski
- Department of Internal Medicine, Olive View – UCLA Medical Center, Sylmar, California
| | - Jason Malenfant
- Division of Infectious Diseases, Olive View – UCLA Medical Center, Sylmar, California
| | - Catherine Yim
- Department of Radiology, Olive View – UCLA Medical Center, Sylmar, California
| | - Arthur Jeng
- Division of Infectious Diseases, Olive View – UCLA Medical Center, Sylmar, California
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16
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Dalal P, Anot K, Monica G, D'Cruz S. Acute paraparesis in HIV-infected patient after initiation of highly active antiretroviral therapy. J Neurovirol 2020; 26:793-796. [PMID: 32671811 DOI: 10.1007/s13365-020-00879-4] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 02/28/2020] [Accepted: 07/03/2020] [Indexed: 11/26/2022]
Abstract
Neurological syndromes occur in around 40-70% of HIV-infected people. Direct central nervous system involvement by the virus usually manifests as HIV encephalitis, HIV leucoencephalopathy, vacuolar leucoencephalopathy or vacuolar myelopathy. Indirect involvement is usually associated with neurotropic opportunistic infections which include tuberculosis, toxoplasmosis, cryptococcosis and viral encephalitis such as herpes simplex, varicella-zoster, cytomegalovirus and Human polyomavirus 2. We report a case of transverse myelitis in a recently diagnosed HIV patient who was otherwise asymptomatic initially and developed paraparesis after 1 month of initiation of antiretroviral therapy. After ruling out opportunistic infections and other causes of compressive and non-compressive myelopathy, development of transverse myelitis was attributed to immune reconstitution inflammatory syndrome in view of baseline low CD4 count and their improvement after HAART initiation. Prompt treatment with corticosteroids successfully reversed the symptoms.
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Affiliation(s)
- Preeti Dalal
- Department of General Medicine, Government Medical College Hospital, Level 4 D Block, Sector 32, Chandigarh, 160030, India
| | - Karuna Anot
- Department of General Medicine, Government Medical College Hospital, Level 4 D Block, Sector 32, Chandigarh, 160030, India
| | - Gupta Monica
- Department of General Medicine, Government Medical College Hospital, Level 4 D Block, Sector 32, Chandigarh, 160030, India.
| | - Sanjay D'Cruz
- Department of General Medicine, Government Medical College Hospital, Level 4 D Block, Sector 32, Chandigarh, 160030, India
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17
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Abstract
We describe a twenty six years old lady with tuberculous meningitis who developed new onset left ptosis and binocular diplopia with features of left fascicular 3rd nerve palsy after 9 months of anti tubercular therapy (ATT) and imaging revealed new onset tuberculoma in the mid-brain. Tuberculoma responded to steroids while continuing ATT. Formation of new tuberculoma as a part of immune reconstitution inflammatory syndrome (IRIS) is possible even after prolonged therapy of 9 months, which responded well to only steroids without altering ATT.
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Affiliation(s)
| | - Vinay Goyal
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India. 110029.
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18
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Aggarwal D, Bhardwaj M, Kumar A, Saini V, Sawal N. Immune reconstitution inflammatory syndrome in non-HIV patients with tuberculosis. A case series. Indian J Tuberc 2020; 67:143-147. [PMID: 32192610 DOI: 10.1016/j.ijtb.2019.02.018] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 02/28/2019] [Indexed: 06/10/2023]
Abstract
Tuberculosis associated Immune reconstitution inflammatory syndrome (IRIS) in a HIV negative patient can present with a multitude of clinic-radiological presentations that are often confused with drug resistance/treatment failure. Being a diagnosis of exclusion, this clinical entity is often prone to under-diagnosis. We present a series of 5 patients who presented with varied but uncommon IRIS manifestations. High index of suspicion coupled with clinical reasoning and judicious use of phenotypic and genotypic culture methods helped in their timely detection and successful treatment.
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Affiliation(s)
- Deepak Aggarwal
- Associate Professor, Dept of Pulmonary Medicine, Govt Medical College & Hospital, Sector-32, Chandigarh, 160030, India.
| | - Manisha Bhardwaj
- Ex-Senior Resident, Dept of Pulmonary Medicine, Govt Medical College & Hospital, Sector-32, Chandigarh, 160030, India
| | - Arjun Kumar
- Junior Resident, Dept of Pulmonary Medicine, Govt Medical College & Hospital, Sector-32, Chandigarh, 160030, India
| | - Varinder Saini
- Professor & Head, Dept of Pulmonary Medicine, Govt Medical College & Hospital, Sector-32, Chandigarh, 160030, India
| | - Nishit Sawal
- Assistant Professor, Dept of General Medicine, Govt Medical College & Hospital, Sector-32, Chandigarh, 160030, India
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19
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Trunfio M, Manini C, Trentalange A, Boghi A, Audagnotto S, Imperiale D, Taraglio S, Bonora S, Di Perri G, Calcagno A. The "milky way" galaxy of HIV-related central nervous system immune reaction syndromes. J Neurovirol 2019; 25:887-892. [PMID: 31214917 DOI: 10.1007/s13365-019-00769-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 11/13/2018] [Revised: 05/18/2019] [Accepted: 05/24/2019] [Indexed: 11/26/2022]
Abstract
The landscape of central nervous system HIV infection is rapidly changing, leading to the recognition of a new constellation of overlapping syndromes and to a better insight for the elder ones. Among these, progressive multifocal leukoencephalopathy (PML) still poses several diagnostic and therapeutic challenges; nevertheless, recent developments in understanding PML in patients with multiple sclerosis may have benefitted HIV-positive patients suffering from PML too. We describe a peculiar case of PML-immune reconstitution inflammatory syndrome (IRIS) presenting a punctate pattern with "milky way" appearance on magnetic resonance imaging. Despite the fact that brain imaging and histopathology remain the mainstays for extricating through the expanding galaxy of HIV-related central nervous system dysimmune syndromes and although punctate pattern has been already well acknowledged as a suggestive finding of PML among patients on natalizumab, this radiological presentation is still poorly recognised in AIDS-related PML cases, leading to possible life-threatening diagnostic delays. This is also the first report about intravenous immunoglobulin treatment in AIDS-related PML-IRIS; the favourable clinical and radiological outcome of our case and the preliminary administrations of intravenous immunoglobulins in natalizumab-associated PML-IRIS from literature support probable benefits also among HIV-positive patients.
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Affiliation(s)
- Mattia Trunfio
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Torino, Corso Svizzera 164, 10149, Torino, Italy.
| | - Claudia Manini
- Unit of Pathology, San Giovanni Bosco Hospital, Piazza Donatore di Sangue 3, 10154, Torino, Italy
| | - Alice Trentalange
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Torino, Corso Svizzera 164, 10149, Torino, Italy
| | - Andrea Boghi
- Unit of Neuroradiology, San Giovanni Bosco Hospital, Piazza Donatore di Sangue 3, 10154, Torino, Italy
| | - Sabrina Audagnotto
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Torino, Corso Svizzera 164, 10149, Torino, Italy
| | - Daniele Imperiale
- Unit of Neurology, Maria Vittoria Hospital, Via Luigi Cibrario 72, 10144, Torino, Italy
| | - Stefano Taraglio
- Unit of Pathology, San Giovanni Bosco Hospital, Piazza Donatore di Sangue 3, 10154, Torino, Italy
| | - Stefano Bonora
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Torino, Corso Svizzera 164, 10149, Torino, Italy
| | - Giovanni Di Perri
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Torino, Corso Svizzera 164, 10149, Torino, Italy
| | - Andrea Calcagno
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Torino, Corso Svizzera 164, 10149, Torino, Italy
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20
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Rowley MW, Patel A, Zhou W, Wong M, Seetharam AB. Immune Reconstitution Syndrome with Initiation of Treatment of HBV/HIV Co-infection: Activity Flare associated with E antigen Seroconversion. Ann Hepatol 2019; 18:220-224. [PMID: 31113594 DOI: 10.5604/01.3001.0012.7918] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 07/17/2017] [Indexed: 02/04/2023]
Abstract
Immune reconstitution syndrome is a recognized complication with initiation of highly active antiretroviral therapy for acquired immune deficiency syndrome patients co-infected with hepatitis B. Hepatitis B flares are seen in 20%-25% of patients after initiation of highly active antiretroviral therapy, an estimated 1%-5% of whom develop clinical hepatitis. We present a case of highly active antiretroviral therapy initiation for HIV that led to a flare of HBV activity despite antiviral therapy directed towards both. Liver biopsy and longitudinal serologic evaluation lend support to the hypothesis that the flare in activity was representative of IRIS. Importantly, we document eAg/eAb seroconversion with the IRIS phenomenon.
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Affiliation(s)
- Michael W Rowley
- Department of Internal Medicine, Banner University Medical Center Phoenix, Phoenix, AZ, USA; Transplant and Advanced Liver Disease Center, Banner University Medical Center Phoenix, Phoenix, AZ, USA.
| | - Amitkumar Patel
- Department of Gastroenterology, Banner University Medical Center Phoenix, Phoenix, AZ, USA; Transplant and Advanced Liver Disease Center, Banner University Medical Center Phoenix, Phoenix, AZ, USA
| | - Wendi Zhou
- Department of Pathology, Banner University Medical Center Phoenix, Phoenix, AZ, USA; University of Arizona College of Medicine Phoenix, Phoenix, AZ, USA
| | - Mark Wong
- Transplant and Advanced Liver Disease Center, Banner University Medical Center Phoenix, Phoenix, AZ, USA; University of Arizona College of Medicine Phoenix, Phoenix, AZ, USA
| | - Anil B Seetharam
- Transplant and Advanced Liver Disease Center, Banner University Medical Center Phoenix, Phoenix, AZ, USA; University of Arizona College of Medicine Phoenix, Phoenix, AZ, USA
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21
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Lo Re V, Petridis I, Živković S, Burgio G, Mularoni A, Milazzo M, Sparacia G, Volpes R, Luca A, Gruttadauria S. Guillain-Barré syndrome after orthotopic liver transplantation: A clinical manifestation of immune reconstitution inflammatory syndrome? Clin Neurol Neurosurg 2018; 173:140-143. [PMID: 30125836 DOI: 10.1016/j.clineuro.2018.07.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 02/22/2018] [Revised: 07/27/2018] [Accepted: 07/29/2018] [Indexed: 11/18/2022]
Abstract
Guillain-Barrè Syndrome, as part of the spectrum of dysimmune neuropathies, is unexpected to occur in immunocompromised hosts. We describe a clinical case of Guillain-Barrè syndrome, occurred a few weeks after a liver transplant, and we postulate that our case would satisfy all requirements to explain this peripheral nervous system complication as a clinical manifestation of an Immune reconstitution inflammatory syndrome. In this setting of liver transplantation, complicated by potentially multiple infective triggers, reduction of immunosuppression and reversal of pathogen-induced immunosuppression, through antimicrobial therapy, may have led to pro-inflammatory response. The pro-inflammatory pattern would have sustained the pathophysiologic mechanism of this immune neuropathy.
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Affiliation(s)
- Vincenzina Lo Re
- Neurology Service, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Via Ernesto Tricomi 5, 90127, Palermo, Italy.
| | - Ioannis Petridis
- Hepatology Unit, Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Via Ernesto Tricomi 5, 90127, Palermo, Italy
| | - Saša Živković
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, 15213, USA
| | - Gaetano Burgio
- Department of Anesthesia and Intensive Care, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Via Ernesto Tricomi 5, 90127, Palermo, Italy
| | - Alessandra Mularoni
- Infectious Disease and Infection Control Service, Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Via Ernesto Tricomi 5, 90127, Palermo, Italy
| | - Mariapina Milazzo
- Radiology Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Via Ernesto Tricomi 5, 90127, Palermo, Italy
| | - Gianvincenzo Sparacia
- Radiology Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Via Ernesto Tricomi 5, 90127, Palermo, Italy
| | - Riccardo Volpes
- Hepatology Unit, Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Via Ernesto Tricomi 5, 90127, Palermo, Italy
| | - Angelo Luca
- Radiology Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Via Ernesto Tricomi 5, 90127, Palermo, Italy
| | - Salvatore Gruttadauria
- Abdominal Surgery and Organ Transplantation Unit, Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Via Ernesto Tricomi 5, 90127, Palermo, Italy
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22
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Watanabe N, Sato R, Nagai H, Matsui H, Yamane A, Kawashima M, Suzuki J, Tashimo H, Ohshima N, Masuda K, Tamura A, Akagawa S, Hebisawa A, Ohta K. An HIV-positive Case of Obstructive Jaundice Caused by Immune Reconstitution Inflammatory Syndrome of Tuberculous Lymphadenitis Successfully Treated with Corticosteroids. Intern Med 2017; 56:2661-2666. [PMID: 28883243 PMCID: PMC5658536 DOI: 10.2169/internalmedicine.8713-16] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 60-year-old man was admitted to our hospital because of a persistent fever with enlargement of multiple lymph nodes in the mediastinum and around the pancreatic head. He was diagnosed with tuberculosis and human immunodeficiency virus infection. We started antiretroviral therapy three weeks after the initiation of anti-tuberculous therapy. Two weeks later, jaundice appeared with dilatation of the biliary tract due to further enlargement of the lymph nodes, which seemed to be immune reconstitution inflammatory syndrome (IRIS). The administration of corticosteroids resolved the obstructive jaundice without surgical treatment or endoscopic drainage. Obstructive jaundice caused by IRIS should first be treated with corticosteroids before invasive treatment.
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Affiliation(s)
- Naoaki Watanabe
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, Japan
| | - Ryota Sato
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, Japan
| | - Hideaki Nagai
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, Japan
| | - Hirotoshi Matsui
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, Japan
| | - Akira Yamane
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, Japan
| | - Masahiro Kawashima
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, Japan
| | - Junko Suzuki
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, Japan
| | - Hiroyuki Tashimo
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, Japan
| | - Nobuharu Ohshima
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, Japan
| | - Kimihiko Masuda
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, Japan
| | - Atsuhisa Tamura
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, Japan
| | - Shinobu Akagawa
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, Japan
| | - Akira Hebisawa
- Department of Clinical Research, National Hospital Organization Tokyo National Hospital, Japan
| | - Ken Ohta
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, Japan
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23
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Abeykoon JP, Abu Saleh OM, Kashiwagi DT. 40-Year-Old Man With Diarrhea and Lymphadenopathy. Mayo Clin Proc 2017; 92:e75-e80. [PMID: 28351507 DOI: 10.1016/j.mayocp.2016.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 07/27/2016] [Accepted: 08/01/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Jithma P Abeykoon
- Resident in Internal Medicine, Mayo School of Graduate Medical Education, Rochester, MN
| | - Omar M Abu Saleh
- Resident in Infectious Diseases, Mayo School of Graduate Medical Education, Rochester, MN
| | - Deanne T Kashiwagi
- Advisor to Residents and Consultant in Hospital Internal Medicine, Mayo Clinic, Rochester, MN.
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24
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Bell L, Peyper JM, Garnett S, Tadokera R, Wilkinson R, Meintjes G, Blackburn JM. TB-IRIS: Proteomic analysis of in vitro PBMC responses to Mycobacterium tuberculosis and response modulation by dexamethasone. Exp Mol Pathol 2017; 102:237-246. [PMID: 28209523 PMCID: PMC5446321 DOI: 10.1016/j.yexmp.2017.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 09/28/2016] [Accepted: 02/11/2017] [Indexed: 12/02/2022]
Abstract
Paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) occurs in 8-54% of South African patients undergoing treatment for tuberculosis/human immunodeficiency virus co-infection. Improved TB-IRIS molecular pathogenesis understanding would enhance risk stratification, diagnosis, prognostication, and treatment. We assessed how TB-IRIS status and dexamethasone influence leukocyte proteomic responses to Mycobacterium tuberculosis (Mtb). Patient blood was obtained three weeks post-anti-retroviral therapy initiation. Isolated mononuclear cells were stimulated ex vivo with heat-killed Mtb in the presence/absence of dexamethasone. Mass spectrometry-based proteomic comparison of TB-IRIS and non-IRIS patient-derived cells facilitated generation of hypotheses regarding pathogenesis. Few represented TB-IRIS-group immune-related pathways achieved significant activation, with relative under-utilisation of "inter-cellular interaction" and "Fcγ receptor-mediated phagocytosis" (but a tendency towards apoptosis-related) pathways. Dexamethasone facilitated significant activation of innate-related pathways. Differentially-expressed non-IRIS-group proteins suggest focused and co-ordinated immunological pathways, regardless of dexamethasone status. Findings suggest a relative deficit in TB-IRIS-group responses to and clearance of Mtb antigens, ameliorated by dexamethasone.
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Affiliation(s)
- Liam Bell
- Department of Integrative Biomedical Sciences & Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, South Africa; Centre for Proteomic and Genomic Research (CPGR), Observatory, 7925 Cape Town, South Africa
| | - Janique M Peyper
- Department of Integrative Biomedical Sciences & Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, South Africa
| | - Shaun Garnett
- Department of Integrative Biomedical Sciences & Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, South Africa
| | - Rabecca Tadokera
- Department of Integrative Biomedical Sciences & Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, South Africa; Clinical Infectious Diseases Research Initiative, IDM, University of Cape Town, Observatory, 7925 South Africa; HIV/AIDS, STIs and TB Programme, Human Sciences Research Council, Arcadia, 0002 Pretoria, South Africa
| | - Robert Wilkinson
- Department of Medicine, Imperial College, London W2 1PG, UK; Clinical Infectious Diseases Research Initiative, IDM, University of Cape Town, Observatory, 7925 South Africa; Department of Medicine, University of Cape Town, Observatory, 7925 South Africa; Francis Crick Institute, Mill Hill Laboratory, London NW7 1AA, UK
| | - Graeme Meintjes
- Clinical Infectious Diseases Research Initiative, IDM, University of Cape Town, Observatory, 7925 South Africa; Department of Medicine, University of Cape Town, Observatory, 7925 South Africa
| | - Jonathan M Blackburn
- Department of Integrative Biomedical Sciences & Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, South Africa.
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Shikawa T, Yanagisawa K, Ogawa Y, Uchiumi H, Gohda F, Handa H. [Successful Treatment of Immune Reconstitution Inflammatory Syndrome with Corticosteroid for Patient with Kaposi's Sarcoma Extending into the Respiratory Tract and Both Lungs]. Kansenshogaku Zasshi 2017; 91:25-30. [PMID: 30277684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
An HIV-infected man in his 30s was transferred to our hospital after the discontinuation of antiretroviral therapy (ART) for 4 years. An intraoral tumor was identified, and a biopsy was performed. The diagnosis was Kaposi's sarcoma (KS) and disseminated lesions were detected in his respiratory tract and both lungs on computed tomography (CT) and 2-[18F] fluoro-2-deoxy-D-glucose positron-emission tomography (FDG/PET) imaging with increasing standardized uptake volume (SUV: max 7.4). On the 7th day, he was intubated to maintain his airway, then antiretroviral therapy and chemotherapy with pegylated liposomal doxorubicin were immediately initiated. After a period of remission, pulmonary lesions were detected again. We regarded them as a manifestation of immune reconstitution inflammatory syndrome (IRIS) and gave him short term corticosteroids. The lesions were then successfully controlled without additional chemotherapy. This case suggests that early induction of ART and intensive care can result in the survival of patients with KS having serious stenosis of the respiratory tract. Furthermore, this presenting case suggested that the use of corticosteroids could be a candidate to control IRIS even in patients with Kaposi's sarcoma.
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Abstract
PURPOSE OF REVIEW Neurologic complications of human immunodeficiency virus (HIV) infection remain common, despite effective antiretroviral treatment (ART). Neurologic manifestations may be due to opportunistic infection, immune reconstitution, or the virus itself, posing diagnostic challenges for the neurologist. Neurologists are also asked to comment on the use of immunomodulatory agents in these patients and to manage long-term complications, such as neurocognitive disorders and peripheral neuropathy or the associated comorbidities. RECENT FINDINGS HIV enters the central nervous system (CNS) soon after infection and can cause atrophy of the brain within 3 months of infection. As patients are living longer, comorbidities such as stroke associated with metabolic syndrome, hepatitis C, and drug abuse are important contributory factors to the neurologic and neuropsychiatric manifestations of HIV infection. Immune-mediated syndromes are increasingly being recognized in patients with HIV infection on antiretroviral therapy. This includes a subacute T-cell-mediated encephalitis called CNS-immune reconstitution inflammatory syndrome, fulminant multiple sclerosis-like lesions, and unmasking of underlying opportunistic infections with profound inflammatory reaction. Our understanding of the most appropriate antiretrovirals for treating or preventing CNS HIV replication continues to improve. Major efforts are being made to understand how the CNS reservoirs are established and maintained, and new approaches are being developed to develop a functional cure or eradicate the virus. SUMMARY This article reviews the neurologic complications caused by HIV infection, associated comorbidities, or antiretroviral drugs that are commonly encountered by neurologists.
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Abstract
The pace of therapeutic developments in HIV presents unique challenges to the neurologist caring for patients. Combination antiretroviral therapy (cART) is remarkably effective in suppressing viral replication, preventing, and often even reversing disease progression. Still, not every patient benefits from cART for a variety of reasons, ranging from the cost of therapy and the burden of lifelong daily treatment to side effects and inadequate access to medical care. Treatment failure inevitably leads to disease progression and opportunistic complications. Many of these complications, even those that are treatable, produce permanent neurological disability. With ART, immune recovery itself may paradoxically lead to severe neurological disease; strategies for managing so-called immune reconstitution inflammatory syndrome are beginning to show benefits. Effective cART may nevertheless leave in its wake persistent neurocognitive impairment. Treatments for persistent impairment despite virologic suppression and good immune recovery are being tested but are not yet proven. As we shall see, these treatments target several proposed mechanisms including cerebral small vessel disease, which is highly prevalent in HIV. Most recently, an ambitious initiative has been undertaken to develop interventions to eradicate HIV. This will require elimination of all infectious forms of viral nucleic acid throughout the body. The influence of these interventions on the brain remains to be characterized. Meanwhile, clinical investigators continue to develop antiretroviral treatments that optimize effectiveness, convenience, and tolerability, while minimizing long-term toxicities.
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Affiliation(s)
- Ronald Ellis
- University of California San Diego, San Diego, CA, USA.
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Iribarren JA, Rubio R, Aguirrebengoa K, Arribas JR, Baraia-Etxaburu J, Gutiérrez F, Lopez Bernaldo de Quirós JC, Losa JE, Miró JM, Moreno S, Pérez Molina J, Podzamczer D, Pulido F, Riera M, Rivero A, Sanz Moreno J, Amador C, Antela A, Arazo P, Arrizabalaga J, Bachiller P, Barros C, Berenguer J, Caylá J, Domingo P, Estrada V, Knobel H, Locutura J, López Aldeguer J, Llibre JM, Lozano F, Mallolas J, Malmierca E, Miralles C, Miralles P, Muñoz A, Ocampo A, Olalla J, Pérez I, Pérez Elías MJ, Pérez Arellano JL, Portilla J, Ribera E, Rodríguez F, Santín M, Sanz Sanz J, Téllez MJ, Torralba M, Valencia E, Von Wichmann MA. Executive summary: Prevention and treatment of opportunistic infections and other coinfections in HIV-infected patients: May 2015. Enferm Infecc Microbiol Clin 2016; 34:517-23. [PMID: 27056581 DOI: 10.1016/j.eimc.2016.02.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 02/15/2016] [Accepted: 02/16/2016] [Indexed: 11/19/2022]
Abstract
Opportunistic infections continue to be a cause of morbidity and mortality in HIV-infected patients. They often arise because of severe immunosuppression resulting from poor adherence to antiretroviral therapy, failure of antiretroviral therapy, or unawareness of HIV infection by patients whose first clinical manifestation of AIDS is an opportunistic infection. The present article is an executive summary of the document that updates the previous recommendations on the prevention and treatment of opportunistic infections in HIV-infected patients, namely, infections by parasites, fungi, viruses, mycobacteria, and bacteria, as well as imported infections. The article also addresses immune reconstitution inflammatory syndrome. This document is intended for all professionals who work in clinical practice in the field of HIV infection.
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Kato H, Yanagisawa N, Morioka H, Sasaki S, Sekiya N, Suganuma A, Imamura A, Ajisawa A. Laryngeal Kaposi's Sarcoma Complicated by the Immune Reconstitution Inflammatory Syndrome in an HIV-infected Patient. Intern Med 2016; 55:1001-5. [PMID: 27086821 DOI: 10.2169/internalmedicine.55.5813] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We herein report a case of laryngeal Kaposi's sarcoma (KS) complicated by immune reconstitution inflammatory syndrome in a human immunodeficiency virus (HIV)-infected patient. The patient initially presented with KS involving the larynx, which was successfully treated with pegylated liposomal doxorubicin (PLD) and antiretroviral therapy (ART). PLD was discontinued after 2 courses because of a marked clinical improvement; however, the patient experienced progressive odynophagia and dyspnea 2 months after the initiation of ART. Laryngoscopy revealed a severely swollen, inflamed epiglottis. The readministration of PLD was successful, and the patient was thereafter discharged without any subsequent complications.
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Affiliation(s)
- Hirofumi Kato
- Department of Infectious Diseases, Tokyo Metropolitan Komagome Hospital, Japan
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30
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Shahani L, Hamill RJ. Therapeutics targeting inflammation in the immune reconstitution inflammatory syndrome. Transl Res 2016; 167:88-103. [PMID: 26303886 DOI: 10.1016/j.trsl.2015.07.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 07/14/2015] [Accepted: 07/31/2015] [Indexed: 02/04/2023]
Abstract
Immune reconstitution inflammatory syndrome (IRIS) is characterized by improvement in a previously incompetent human immune system manifesting as worsening of clinical symptoms secondary to the ability of the immune system to now mount a vigorous inflammatory response. IRIS was first recognized in the setting of human immunodeficiency virus, and this clinical setting continues to be where it is most frequently encountered. Hallmarks of the pathogenesis of IRIS, independent of the clinical presentation and the underlying pathogen, include excessive activation of the immune system, with increased circulating effector memory T cells, and elevated levels of serum cytokines and inflammatory markers. Patients with undiagnosed opportunistic infections remain at risk for unmasking IRIS at the time of active antiretroviral therapy (ART) initiation. Systematic screening for opportunistic infections before starting ART is a key element to prevent this phenomenon. Appropriate management of IRIS requires prompt recognition of the syndrome and exclusion of alternative diagnoses, particularly underlying infections and drug resistance. Controlled studies supporting the use of pharmacologic interventions in IRIS are scare, and recommendations are based on case series and expert opinions. The only controlled trial published to date, showed reduction in morbidity in patients with paradoxical tuberculosis-related IRIS with the use of oral corticosteroids. There are currently limited data to recommend other anti-inflammatory or immunomodulatory therapies that are discussed in this review, and further research is needed. Ongoing research regarding the immune pathogenesis of IRIS will likely direct future rational therapeutic approaches and clinical trials.
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Affiliation(s)
- Lokesh Shahani
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Tex
| | - Richard J Hamill
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Tex; Medical Care Line, Section of Infectious Diseases, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex.
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Manea E, Munteanu D, Jipa R, Moroti R, Arama V, Diaconu IA, Hristea A. Immune reconstitution inflammatory syndrome in central nervous system tuberculosis. Pneumologia 2015; 64:32-36. [PMID: 27451593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Immune reconstitution inflammatory syndrome (IRIS) related to tuberculosis (TB) is an exacerbation of an inflammatory response that most often occurs in HIV-infected patients but it has also been observed in non-HIV immunocompromised hosts. We describe two cases of TB associated IRIS with CNS involvement, one in a patient diagnosed with HIV infection and the other in a patient with immunosuppression due to anti tumor necrosis factor treatment. CASE REPORT; The first case was a 40-year-old man, newly diagnosed with HIV infection, who developed right hemiplegia and expressive aphasia. Lumbar puncture and MRI sustained the diagnosis of TB meningoencephalitis. He initially improved understandard antituberculous therapy (ATT). After 6 weeks of ATT antiretroviral treatment (ART) was initiated and one week later the patient experienced worsening of his symptoms (left hemiparesis and mixed aphasia), of CSF and MRI changes. He improved after he was starting on corticosteroids in tapering doses, with clinical deterioration at lower doses over a 5-month period. The second case was a 56-year-old male, treated for 3 years with Infliximab for ankylosing spondylitis. He was diagnosed with disseminated TB (CNS tuberculomas and pulmonary TB), histological and bacteriological confirmed the diagnosis. His neurological symptoms improved after starting ATT but after 2 weeks of therapy he presented with diplopia and generalized tonic-clonic seizures. These symptoms improved only after corticosteroids were added (tapering doses during the next 6 months). CONCLUSION TB-associated IRIS with CNS involvement is potentially life threatening. Corticosteroids should be used to control the IRIS symptoms in those patients. The dosing and duration should be tailored to each patient.
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van Lier DPT, Janssen NAF, Snoeren MM, Verweij PE, Blijlevens NMA, van der Velden WJFM. [Severe inflammation during recovery from neutropenia: the immune reconstitution inflammatory syndrome following chemotherapy]. Ned Tijdschr Geneeskd 2015; 159:A8968. [PMID: 26246060] [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] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Immune reconstitution inflammatory syndrome (IRIS) occurs when a patient is recovering from a transient immunodeficiency and results in an uncontrolled inflammatory response to infectious agents and tissue damage. Symptoms such as fever and radiological signs seem to paradoxically appear or worsen, unmasking a previously unrecognized infection. The patient's clinical condition may then deteriorate as a result of increasing tissue damage and this may even lead to death. IRIS was initially described in patients suffering from a HIV infection who experienced immune recovery following the initiation of antiretroviral therapy. Increasingly, however, the syndrome is being reported in patients who are recovering from an episode of neutropenia following chemotherapy, hypomethylating agent use or a stem cell transplantation for the treatment of a solid tumour or haematological cancers. We describe two cases of IRIS following an episode of neutropenia in patients with a haematological malignancy and elaborate on the pathogenesis, diagnosis and treatment of IRIS in cancer patients.
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Vayssade M, Tournadre A, D'Incan M, Soubrier M, Dubost JJ. Immune reconstitution inflammatory syndrome during treatment of Whipple's disease. Joint Bone Spine 2014; 82:122-4. [PMID: 25553832 DOI: 10.1016/j.jbspin.2014.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [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: 06/03/2014] [Accepted: 09/07/2014] [Indexed: 12/17/2022]
Abstract
Immune reconstitution inflammatory syndrome is a rare complication of the treatment of Whipple's disease. Here, we report the case of a 65-year-old man treated for Whipple's disease affecting the joints, with positive Tropheryma whipplei PCR in CSF, who developed fever and nodular eruption on the trunk, arms and face in association with biological inflammatory syndrome 10 days after initiation of antimicrobial treatment. Skin manifestations and the patient's general condition improved on corticosteroids (0.5mg/kg prednisone), but as steroids were gradually tapered, new nodules appeared below a prednisone dose of 10-15mg. One year after starting treatment, lumbar puncture showed asymptomatic meningitis with negative T. whipplei PCR results which had regressed spontaneously. Two years after the diagnosis, on prednisone 5mg daily and antimicrobial treatment, the patient had only transient, episodic nodular rash without fever or inflammatory syndrome.
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Affiliation(s)
- Marielle Vayssade
- Department of Rheumatology, Clermont-Ferrand 1 University, G. Montpied Hospital, 58, rue Montalembert, BP 69, 63003 Clermont-Ferrand cedex 1, France
| | - Anne Tournadre
- Department of Rheumatology, Clermont-Ferrand 1 University, G. Montpied Hospital, 58, rue Montalembert, BP 69, 63003 Clermont-Ferrand cedex 1, France
| | - Michel D'Incan
- Department of Dermatology, Estaing Hospital, Clermont-Ferrand 1 University, 1 place Lucie-et-Raymond-Aubrac, 63003 Clermont-Ferrand cedex 1 France
| | - Martin Soubrier
- Department of Rheumatology, Clermont-Ferrand 1 University, G. Montpied Hospital, 58, rue Montalembert, BP 69, 63003 Clermont-Ferrand cedex 1, France
| | - Jean-Jacques Dubost
- Department of Rheumatology, Clermont-Ferrand 1 University, G. Montpied Hospital, 58, rue Montalembert, BP 69, 63003 Clermont-Ferrand cedex 1, France.
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Read PJ, Lucas S, Morris S, Kulasegaram R. Immune reconstitution inflammatory syndrome Kaposi sarcoma in the liver manifesting as acute obstructive hepatitis: another potential role for montelukast? Int J STD AIDS 2014; 24:156-8. [PMID: 24400347 DOI: 10.1177/0956462412472819] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Immune reconstitution inflammatory syndrome has been described in Kaposi sarcoma, but does not usually manifest as acute hepatitis. We describe a case of rapid obstructive jaundice after initiation of antiretroviral therapy, in which the liver biopsy confirmed hepatic Kaposi sarcoma, and the clinical course was altered by the addition of montelukast.
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Abstract
UNLABELLED HIV is the top and tuberculosis is the second leading cause of death from infectious disease worldwide, with an estimated 8.7 million incident cases of tuberculosis and 2.5 million new HIV infections annually. The World Health Organization estimates that HIV prevalence among children with tuberculosis, in countries with moderate to high prevalence, ranges from 10 to 60%. The mechanisms promoting susceptibility of people with HIV to tuberculosis disease are incompletely understood, being likely caused by multifactorial processes. Paediatric tuberculosis and HIV have overlapping clinical manifestations, which could lead to missed or late diagnosis. Although every effort should be made to obtain a microbiologically-confirmed diagnosis in children with tuberculosis, in reality this may only be achieved in a minority, reflecting their paucibacillary nature and the difficulties in obtain samples. Rapid polymerase chain reaction tests, such as Xpert MTB/RIF assay, are increasingly used in children. The use of less or non invasive methods of sample collection, such as naso-pharyngeal aspirates and stool samples for a polymerase chain reaction-based diagnostic test tests and mycobacterial cultures is promising technique in HIV negative and HIV positive children. Anti-tuberculosis treatment should be started immediately at diagnosis with a four drug regimen, irrespective of the disease severity. Moreover, tuberculosis disease in an HIV infected child is considered to be a clinical indication for initiation of antiretroviral treatment. The World Health Organization recommends starting antiretroviral treatment in children as soon as anti-tuberculosis treatment is tolerated and within 2- 8 weeks after initiating it. The treatment of choice depends on the child's age and availability of age-appropriate formulations, and potential drug interactions and resistance. Treatment of multidrug resistant tuberculosis in HIV-infected children follows same principles as for HIV uninfected children. There are conflicting results on effectiveness of isoniazid preventive therapy in reducing incidence of tuberculosis disease in children with HIV. CONCLUSION Data on HIV/TB co-infection in children are still lacking. There are on-going large clinical trials on the prevention and treatment of TB/HIV infection in children that hopefully will help to guide an evidence-based clinical practice in both resource-rich and resource-limited settings.HIV is the top and tuberculosis is the second leading cause of death from infectious disease worldwide, with an estimated 8.7 million incident cases of tuberculosis and 2.5 million new HIV infections annually. The World Health Organization estimates that HIV prevalence among children with tuberculosis, in countries with moderate to high prevalence, ranges from 10 to 60%. The mechanisms promoting susceptibility of people with HIV to tuberculosis disease are incompletely understood, being likely caused by multifactorial processes.
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Affiliation(s)
- Elisabetta Venturini
- Department of Health Sciences, Meyer Children University Hospital, University of Florence, Florence, Italy
| | - Anna Turkova
- Department of Paediatric Infectious Diseases, St Mary's Hospital, Imperial College NHS Trust, London, United Kingdom
| | - Elena Chiappini
- Department of Health Sciences, Meyer Children University Hospital, University of Florence, Florence, Italy
| | - Luisa Galli
- Department of Health Sciences, Meyer Children University Hospital, University of Florence, Florence, Italy
| | - Maurizio de Martino
- Department of Health Sciences, Meyer Children University Hospital, University of Florence, Florence, Italy
| | - Claire Thorne
- Centre of Paediatric Epidemiology and Biostatistics, University College London Institute of Child Health, London, WC1N 1EH, United Kingdom
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Wattjes MP, Verhoeff L, Zentjens W, Killestein J, van Munster ET, Barkhof F, van Eijk JJJ. Punctate lesion pattern suggestive of perivascular inflammation in acute natalizumab-associated progressive multifocal leukoencephalopathy: productive JC virus infection or preclinical PML-IRIS manifestation? J Neurol Neurosurg Psychiatry 2013; 84:1176-7. [PMID: 23695498 DOI: 10.1136/jnnp-2013-304986] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
MESH Headings
- Anti-Inflammatory Agents/therapeutic use
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/therapeutic use
- Brain/blood supply
- Brain/pathology
- Cerebral Arteries/pathology
- Combined Modality Therapy
- Diagnosis, Differential
- Female
- Humans
- Image Enhancement
- Image Interpretation, Computer-Assisted
- Immune Reconstitution Inflammatory Syndrome/chemically induced
- Immune Reconstitution Inflammatory Syndrome/diagnosis
- Immune Reconstitution Inflammatory Syndrome/drug therapy
- Infusions, Intravenous
- Leukoencephalopathy, Progressive Multifocal/chemically induced
- Leukoencephalopathy, Progressive Multifocal/diagnosis
- Magnetic Resonance Imaging
- Methylprednisolone/therapeutic use
- Middle Aged
- Multiple Sclerosis, Relapsing-Remitting/diagnosis
- Multiple Sclerosis, Relapsing-Remitting/drug therapy
- Natalizumab
- Neurologic Examination/drug effects
- Plasma Exchange
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Chang CC, Omarjee S, Lim A, Spelman T, Gosnell BI, Carr WH, Elliott JH, Moosa MYS, Ndung'u T, French MA, Lewin SR. Chemokine levels and chemokine receptor expression in the blood and the cerebrospinal fluid of HIV-infected patients with cryptococcal meningitis and cryptococcosis-associated immune reconstitution inflammatory syndrome. J Infect Dis 2013; 208:1604-12. [PMID: 23908492 DOI: 10.1093/infdis/jit388] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [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: 02/07/2023] Open
Abstract
BACKGROUND Human immunodeficiency virus-infected patients with treated cryptococcal meningitis who start combination antiretroviral therapy (cART) are at risk of further neurological deterioration, in part caused by paradoxical cryptococcosis-associated immune reconstitution inflammatory syndrome (C-IRIS). We hypothesized that C-IRIS is associated with alterations of chemokine receptor expression on T cells and chemokine concentrations in cerebrospinal fluid (CSF) that enhance recruitment of T-helper 1 cells and/or myeloid cells to the central nervous system. METHODS In a prospective study of 128 human immunodeficiency virus-infected patients with cryptococcal meningitis who received antifungal therapy followed by cART, we examined the proportions of CD4(+) and CD8(+) T cells expressing CCR5 and/or CXCR3, in CSF and whole blood and the concentrations of CXCL10, CCL2, and CCL3 in stored CSF and plasma. RESULTS The proportion of CD4(+) and CD8(+) T cells expressing CXCR3(+)CCR5(+) and the concentrations of CXCL10, CCL2 and CCL3 were increased in CSF compared with blood at cART initiation (P < .0001). Patients with C-IRIS (n = 26), compared with those with no neurological deterioration (n = 63), had higher CSF ratios of CCL2/CXCL10 and CCL3/CXCL10 and higher proportions of CXCR3(+)CCR5(+)CD8(+)T cells in CSF compared with blood at cART initiation (P = .03, .0053, and .02, respectively). CONCLUSION CD8(+) T-cell and myeloid cell trafficking to the central nervous system may predispose patients to C-IRIS.
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Zaffiri L, Verma R, Struzzieri K, Monterroso J, Batts DH, Loehrke ME. Immune reconstitution inflammatory syndrome involving the central nervous system in a patient with HIV infection: a case report and review of literature. New Microbiol 2013; 36:89-92. [PMID: 23435821] [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] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Accepted: 10/12/2012] [Indexed: 06/01/2023]
Abstract
IRIS is described as a paradoxical deterioration of clinical status upon initiation of combined anti-retroviral therapy (cART) in patients with HIV infection. Immune reconstitution inflammatory syndrome (CNS-IRIS) involving the central nervous system is rarely reported. We describe the case of 57-year-old man who developed a fatal case of CNS- IRIS. A rapid deterioration of neurological status was associated with progression of patchy T2-weighted hyperintensities involving different vascular territories on brain MRI. Diagnosis of CNS-IRIS is based of laboratory and radiologic findings, however brain biopsy is supportive. Despite immune restoration being involved in clinical deterioration, discontinuation of cART is not recommended. The use of corticosteroids is highly controversial. Prompt recognition of CNS-IRIS is crucial for preventing neurological complications and ensuing sequelae.
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Affiliation(s)
- Lorenzo Zaffiri
- Department of Internal Medicine, Western Michigan University School of Medicine, Kalamazoo, MI, USA.
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Young BE, Yeo TR, Lim HT, Vong KY, Tan K, Lye DC, Lee CC. Progressive Multifocal Leukoencephalopathy with Immune Reconstitution Inflammatory Syndrome (PML-IRIS): two case reports of successful treatment with mefloquine and a review of the literature. Ann Acad Med Singap 2012; 41:620-624. [PMID: 23303123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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Curran A, Falcó V, Pahissa A, Ribera E. Management of tuberculosis in HIV-infected patients. AIDS Rev 2012; 14:231-246. [PMID: 23258298] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
HIV-tuberculosis coinfection is currently one of the greatest health threats, affecting millions of people worldwide, with high morbidity and mortality. Treating both infections can be a challenge and requires some expertise due to multidirectional drug interactions, risk of overlapping side effects, high pill burden and risk of immune reconstitution inflammatory syndrome. This article reviews the general management of tuberculosis/HIV coinfection, focusing on the optimal time to start antiretroviral therapy and which treatments can be safely used. The randomized clinical trials designed to answer the question of when to start antiretroviral therapy (SAPIT, CAMELIA, STRIDE and TIME), published in the last two years, are described and discussed in detail. Summarizing these trials' conclusions, antiretroviral therapy should be started within two weeks of starting tuberculosis treatment if the patient has less than 50 CD4/mm3 and wait to the end of the induction phase (8-12 weeks after starting tuberculosis treatment) if higher CD4 cell counts exist. Treatment options for both tuberculosis and HIV, including the newer available drugs and those in clinical trials, are revised and recommendations for dose adjustments are made based on the latest available literature, with special attention to drug-drug interactions and the necessity of dose adjustments with some drug combinations.
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Affiliation(s)
- Adrian Curran
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.
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Affiliation(s)
- N Deborah Friedman
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia.
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Musubire AK, Meya BD, Mayanja-Kizza H, Lukande R, Wiesner LD, Bohjanen P, R Boulware RD. Challenges in diagnosis and management of Cryptococcal immune reconstitution inflammatory syndrome (IRIS) in resource limited settings. Afr Health Sci 2012; 12:226-30. [PMID: 23056032 DOI: 10.4314/ahs.v12i2.23] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [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] [Indexed: 02/06/2023] Open
Abstract
In many resource-limited settings, cryptococcal meningitis (CM) contributes up to 20% of all deaths with further complications due to Immune Reconstitution Inflammatory Syndrome (IRIS). We present a case report on a patient who developed CM-IRIS and then subsequent CM-relapse with a fluconazole-resistant organism and then later CM-IRIS once again, manifesting as cystic cryptococcomas, hydrocephalus, and sterile CSF. In this case we, demonstrate that CM-IRIS and persistent low level cryptococcal infection are not mutually exclusive phenomena. The management of IRIS with corticosteroids may increase the risk of culture positive CM-relapse which may further increase the risk of recurrent IRIS and resulting complications including death. We also highlight the role of imaging and fluconazole resistance testing in patients with recurrent meningitis and the importance of CSF cultures in guiding treatment decisions.
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Affiliation(s)
- A K Musubire
- Infectious Disease Institute, College of Health Sciences, Makerere University, Kampala, Uganda.
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Yong L. Cryptococcal immune reconstitution syndrome in HIV-negative patients. Int J Infect Dis 2011; 15:e884. [PMID: 21982695 DOI: 10.1016/j.ijid.2011.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Accepted: 09/01/2011] [Indexed: 11/28/2022] Open
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Ellis RM, Mohr MR, Oldfield EC, Hood AF. Recalcitrant herpetic scrotal ulcer as a manifestation of immune reconstitution inflammatory syndrome. J Am Acad Dermatol 2011; 65:456-457. [PMID: 21763588 DOI: 10.1016/j.jaad.2010.03.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2009] [Revised: 03/30/2010] [Accepted: 03/31/2010] [Indexed: 11/18/2022]
Affiliation(s)
- Rachel M Ellis
- Department of Dermatology, Eastern Virginia Medical School, Norfolk, Virginia
| | - Melinda R Mohr
- Department of Dermatology, Eastern Virginia Medical School, Norfolk, Virginia.
| | - Edward C Oldfield
- Department of Internal Medicine, Division of Infectious Diseases, Eastern Virginia Medical School, Norfolk, Virginia
| | - Antoinette F Hood
- Department of Dermatology, Eastern Virginia Medical School, Norfolk, Virginia
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Ali K, Klotz SA. The immune reconstitution inflammatory syndrome with tuberculosis: a common problem in Ethiopian HIV-infected patients beginning antiretroviral therapy. ACTA ACUST UNITED AC 2011; 11:198-202. [PMID: 21521804 DOI: 10.1177/1545109711402212] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The Immune Reconstitution Inflammatory Syndrome (IRIS) in Ethiopian HIV-infected patients coinfected with tuberculosis (TB) was studied. HIV-infected outpatients initiating antiretroviral therapy (ART) at an HIV clinic in northern Ethiopia from January 2007 through September 2008 were identified (n = 1977). Patients with TB-IRIS occurring within 6 months of starting ART (n = 143) were compared with a control group of patients with HIV who began ART but did not develop TB-IRIS (n = 277). ART was not interrupted in any patient. Eleven (8%) patients with TB-IRIS died. New or "unmasked" TB with accompanying IRIS occurred in 132 or 92% of the cases. Worsening or "paradoxical" TB (ie, already known to be present and treated) was accompanied by IRIS in 11 (8%) patients. There was no significant difference between "unmasked" and "paradoxical" cases with respect to presentation of disease and outcome. Only a low baseline CD4 count (mean: 102 cells/μL) and a past history of World Health Organization (WHO) Clinical Stage 3 or 4 were associated with TB-IRIS (P < .05). The clinical manifestations of TB-IRIS were diverse, requiring a high index of suspicion. For example, pleural disease occurred in 13 patients, TB lymphadenitis in 17, intracranial TB in 9 patients, and disseminated TB in 15 patients. The majority of patients (88%) responded to continuation of ART and TB therapy. Thus, TB-IRIS is common in Ethiopian patients beginning ART, occurring in 7% of patients initiating antiretroviral therapy.
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Affiliation(s)
- Kedir Ali
- 1Dessie Referral Hospital, Dessie, Ethiopia
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Yashiro S, Takeda N, Uemura A, Nakamura Y, Kasagi A, Yoshida N, Kikuchi Y, Oka S. [Severe case of cytomegalovirus-associated immune reconstitution syndrome in AIDS]. Nippon Ganka Gakkai Zasshi 2011; 115:34-40. [PMID: 21348231] [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] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND Immune reconstitution syndrome (IRS) is a complication caused by reactivation of the immune system that can occur after starting highly active antiretroviral therapy (HAART) in patients with acquired immunodeficiency syndrome (AIDS). Severe IRS associated with cytomegalovirus (CMV) in both eyes who had lost his left vision is reported. CASE A 37-year-old man with AIDS who had started HAART discontinued his medication. Two weeks after the re-induction of HAART, he suffered CMV retinitis OU. Vitreous opacity OU appeared 3 days later, and optic neuritis OS appeared 6 days after the onset; and visual acuity OS decreased to 0.06. As the number of CD 4 positive T lymphocytes (CD 4) increased from 39 to 118/microl in both the pre- and- post HAART, we diagnosed IRS and started anti- CMV and systemic steroid therapy and discontinued the HAART. The focus of CMV retinitis was improved; however, visual acuity OS did not improve. CONCLUSION Severe IRS with visual loss induced by CMV retinitis after HAART needs to be considered in low CD 4 level patients during the induction phase.
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Affiliation(s)
- Shigeko Yashiro
- Department of Ophthalmology, Hospital, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan.
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Shiohara T, Kurata M, Mizukawa Y, Kano Y. Recognition of immune reconstitution syndrome necessary for better management of patients with severe drug eruptions and those under immunosuppressive therapy. Allergol Int 2010; 59:333-43. [PMID: 20962568 DOI: 10.2332/allergolint.10-rai-0260] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Indexed: 12/16/2022] Open
Abstract
The immune reconstitution syndrome (IRS) is an increasingly recognized disease concept and is observed with a broad-spectrum of immunosuppressive therapy-related opportunistic infectious diseases and severe drug eruptions complicated by viral reactivations. Clinical illness consistent with IRS includes tuberculosis, herpes zoster, herpes simples, cytomegalovirus infections and sarcoidosis: thus, the manifestations of this syndrome and diverse and depend on the tissue burden of the preexisting infectious agents during the immunosuppressive state, the nature of the immune system being restored, and underlying diseases of the hosts. Although IRS has originally been reported to occur in the setting of HIV infection, it has become clear that the development of IRS can also be in HIV-negative hosts receiving immunosuppressive agents, such as prednisolone and tumor necrosis factor α inhibitors, upon their reduction and withdrawal. Drug-induced hypersensitivity syndrome, a life-threatening multiorgan system reaction, is another manifestation of the newly observed IRS. Clinical recognition of the IRS is especially important in improving the outcome for diseases with an otherwise life-threatening progenosis. Clinicians should be aware of the implications of IRS and recognize that relieving the symptoms and signs of immune recovery by anti-inflammatory therapies needs to be balanced with anti-microbial therapies aiming at reducing the amplitude and duration of tissue burden of preexisting microbes.
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Affiliation(s)
- Tetsuo Shiohara
- Department of Dermatology, Kyorin University School of Medicine, Tokyo, Japan. −u.ac.jp
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Pornprasert S, Leechanachai P, Klinbuayaem V, Leenasirimakul P, Promping C, Inta P, Ajhan S. Unmasking tuberculosis-associated immune reconstitution inflammatory syndrome in HIV-1 infection after antiretroviral therapy. Asian Pac J Allergy Immunol 2010; 28:206-209. [PMID: 21038792] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The exaggerated immune response to the subclinical opportunistic microorganisms or their antigens can be found in HIV-1 infected patients after receiving antiretroviral (ARV) therapy. We report a case of unmasking tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) in the HIV-1 infected patient who had no previous history of mycobacterial infection. She had tuberculosis of intestines, peritoneum and mesenteric glands within 2 months of ARV. However, her sputum acid-fast bacilli stain, sputum, blood and cervical lymph node aspiration cultures for mycobacterium were negative. Her CD4 cell count increased of from 46 cells/microL at baseline before receiving ARV to 155 cells/microL at month 6 of ARV. In addition, her plasma pro-inflammatory (IFN-gamma and TNF-alpha) and anti-inflammatory (IL-10) cytokine measurement was supported the occurrence of immune restoration reaction. Therefore, the changing in these cytokine profiles may be an important marker of developing unmasking TB-IRIS.
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Affiliation(s)
- Sakorn Pornprasert
- Faculty of Associated Medical Sciences, Chiang-Mai University, Chiang-Mai.
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