Immune reconstitution syndrome: Difference between revisions
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==Clinical Features== | ==Clinical Features== | ||
*Symptoms of underlying illness within 1 week to a few months after initiating ART | *Symptoms of underlying illness within 1 week to a few months after initiating ART | ||
*Fever (especially with mycobacterial or cryptococcal infections) | *[[Fever]] (especially with mycobacterial or cryptococcal infections)<ref>Cheng VC, Yuen KY, Chan WM, Wong SS, Ma ES, Chan RM. Immunorestitution disease involving the innate and adaptive response. Clin Infect Dis. 2000;30(6):882–892. doi:10.1086/313809</ref> | ||
*Manifestations of the underlying disease process: | *Manifestations of the underlying disease process: | ||
**[[Tuberculosis]] | **[[Tuberculosis]] | ||
**[[Mycobacterium avium]] | **[[Mycobacterium avium]] | ||
**Cryptococcus | **[[Cryptococcus neoformans]] | ||
**[[Cytomegalovirus]] | **[[Cytomegalovirus]] | ||
*[[JC virus | **[[Progressive multifocal leukoencephalopathy]] (associated with the JC virus) | ||
*[[Pneumocystis jirovecii pneumonia]] | **[[Pneumocystis jirovecii pneumonia]] | ||
*[[Herpes zoster]] | **[[Herpes zoster]] | ||
*[[Hepatitis B]] | **[[Hepatitis B]] | ||
*[[Leishmaniasis]] | **[[Leishmaniasis]] | ||
*[[Kaposi sarcoma]] | **[[Kaposi sarcoma]] | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
*Progression of [[HIV]]/[[AIDS]] | |||
*Antimicrobial resistance | |||
*Medication noncompliance | |||
*Development of new opportunistic infection rather than recrudescence | |||
*Drug toxicity | |||
==Evaluation== | ==Evaluation== | ||
| Line 39: | Line 43: | ||
==Management== | ==Management== | ||
*Continue ART | |||
*Treatment of underlying opportunistic infection | |||
*[[Glucocorticoids]] may be indicated as adjunct therapy for severe cases | |||
==Disposition== | ==Disposition== | ||
*Disposition depends on severity of the immune response as well as the specific underlying disease process. Consider admission if unstable, poor follow-up, or severe illness. | |||
==See Also== | ==See Also== | ||
*[[HIV]] | |||
*[[AIDS]] | |||
*[[Mycobacterium tuberculosis]] | |||
*[[Mycobacterium avium]] | |||
*[[Cytomegalovirus]] | |||
*[[Cryptococcus neoformans]] | |||
*[[Pneumocystis jirovecii]] | |||
*[[Herpes simplex virus]] | |||
==External Links== | ==External Links== | ||
| Line 52: | Line 65: | ||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:ID]] | |||
Latest revision as of 17:21, 25 October 2020
Background
Immune reconstitution syndrome, or immune reconstitution inflammatory syndrome (IRIS), refers to the paradoxical worsening of pre-existing infections after antiretroviral therapy (ART) is intiated for HIV.[1] It occurs due to increases in T lymphocyte numbers that occurs after ART is started as well as increased immune response.
Clinical Features
- Symptoms of underlying illness within 1 week to a few months after initiating ART
- Fever (especially with mycobacterial or cryptococcal infections)[2]
- Manifestations of the underlying disease process:
Differential Diagnosis
- Progression of HIV/AIDS
- Antimicrobial resistance
- Medication noncompliance
- Development of new opportunistic infection rather than recrudescence
- Drug toxicity
Evaluation
Diagnostic Criteria
The diagnosis of IRIS is clinical. Most of the following criteria should be present to make the diagnosis:[3]
- Presence of AIDS with low pretreatment CD4 count. Usually this is <100, but tuberculosis can be reactivated with CD4 cells >200.
- Positive virologic and immunologic response to ART
- Absence of evidence of drug-resistant infection, bacterial superinfection, adverse drug reaction, patient noncompliance, or reduced serum drug levels
- Presence of clinical manifestations consistent with inflammatory condition
- Temporal association between ART initiation and the onset of clinical features of illness
Commonly Associated Pathogens
- Mycobacterium tuberculosis
- Mycobacterium avium
- Cytomegalovirus
- Cryptococcus neoformans
- Pneumocystis jirovecii
- Herpes simplex virus
- Hepatitis B[4]
Management
- Continue ART
- Treatment of underlying opportunistic infection
- Glucocorticoids may be indicated as adjunct therapy for severe cases
Disposition
- Disposition depends on severity of the immune response as well as the specific underlying disease process. Consider admission if unstable, poor follow-up, or severe illness.
See Also
- HIV
- AIDS
- Mycobacterium tuberculosis
- Mycobacterium avium
- Cytomegalovirus
- Cryptococcus neoformans
- Pneumocystis jirovecii
- Herpes simplex virus
External Links
References
- ↑ DeSimone JA, Pomerantz RJ, Babinchak TJ. Inflammatory reactions in HIV-1-infected persons after initiation of highly active antiretroviral therapy. Ann Intern Med. 2000;133(6):447–454. doi:10.7326/0003-4819-133-6-200009190-00013
- ↑ Cheng VC, Yuen KY, Chan WM, Wong SS, Ma ES, Chan RM. Immunorestitution disease involving the innate and adaptive response. Clin Infect Dis. 2000;30(6):882–892. doi:10.1086/313809
- ↑ Haddow LJ, Easterbrook PJ, Mosam A, et al. Defining immune reconstitution inflammatory syndrome: evaluation of expert opinion versus 2 case definitions in a South African cohort. Clin Infect Dis. 2009;49(9):1424–1432. doi:10.1086/630208
- ↑ Shelburne SA 3rd, Hamill RJ, Rodriguez-Barradas MC, et al. Immune reconstitution inflammatory syndrome: emergence of a unique syndrome during highly active antiretroviral therapy. Medicine (Baltimore). 2002;81(3):213–227. doi:10.1097/00005792-200205000-00005