Immune reconstitution inflammatory syndrome: Difference between revisions
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==Background== | ==Background== | ||
*Also called IRIS | *Also called IRIS | ||
*Definition-Disease or pathogen specific inflammatory response in HIV infected patients after initiation or re-initiation of ARV therapy or after change to more active ARV therapy. | *Definition-Disease or pathogen specific inflammatory response in [[HIV]] infected patients after initiation or re-initiation of ARV therapy or after change to more active ARV therapy. | ||
*Usually low CD4 counts and high viral loads at time of ARV initiation | |||
*Can occur at any CD4 count | |||
*Occurs usually within 4-8 weeks after initiation of therapy | |||
==Clinical Features== | ==Clinical Features== | ||
===Major Presentations=== | |||
*[[TB]]- worsening TB symptoms | |||
*[[mycobacterium avium|MAC]]- localized [[lymphadenitis]], pulmonary disease, systemic inflammation indistinguishable from active MAC | |||
**MAC-IRIS patients are not bacteremic | |||
*[[Cryptococcosis]]- worsening meningitis symptoms | |||
*[[CMV]]- [[CMV retinitis|retinitis]], vitritis, [[uveitis]] | |||
**IRIS due to CMV can cause vision loss | |||
***mean time to vitritis 20 weeks | |||
*[[viral hepatitis|Hepatitis]] B or C- transient transaminitis difficult to distinguish from drug induced cause | |||
**hepatic flares usually mild, may decompensate cirrhotics. | |||
*[[Progressive multifocal leukoencephalopathy]]- worsening focal neuro lesions, changes on [[brain MRI|MRI]] | |||
*[[Kaposi's Sarcoma]]- worsening Kaposi's | |||
*Autoimmune diseases- Pre-existing autoimmune disorder exacerbation | |||
===Minor Presentations=== | |||
*[[Herpes Simplex Virus]] and [[Varicella zoster virus]] reactivation | |||
*Non-specific derm- many including oral and genital warts | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
*New infection not associated with IRIS (i.e. bacterial [[meningitis]]) | |||
*Opportunistic [[infection]] | |||
== | {{HIV associated conditions}} | ||
==Evaluation== | |||
*Index of suspicion with known recent initiation of ARV's | |||
*System specific testing ([[CXR]], [[LP]] etc) | |||
==Management== | ==Management== | ||
===Mild IRIS=== | |||
*Standard therapy for offending opportunistic info (i.e. [[acyclovir]] for HSV) | |||
*Largely supportive care | |||
**[[NSAIDs]] for mild symptoms | |||
**[[Inhaled steroids]] for pulmonary symptoms | |||
*Continue ARV except in severe IRIS (see below) | |||
===Severe IRIS=== | |||
*Defined as a threat to functional status or permanent disability (i.e. vision loss from CMV) | |||
*Severe IRIS- [[prednisone]] 1-2mg/kg (consult HIV/ID) for 1-2 weeks then taper | |||
==Disposition== | ==Disposition== | ||
*Admit for severe IRIS. | |||
*Dispo in conjunction with HIV/ID consult. | |||
==See Also== | ==See Also== | ||
*[[HIV - AIDS (Main)]] | |||
*[[HIV diarrhea]] | |||
==External Links== | ==External Links== | ||
*www.hivguidelines.org | |||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:ID]] | |||
Latest revision as of 01:17, 2 October 2019
Background
- Also called IRIS
- Definition-Disease or pathogen specific inflammatory response in HIV infected patients after initiation or re-initiation of ARV therapy or after change to more active ARV therapy.
- Usually low CD4 counts and high viral loads at time of ARV initiation
- Can occur at any CD4 count
- Occurs usually within 4-8 weeks after initiation of therapy
Clinical Features
Major Presentations
- TB- worsening TB symptoms
- MAC- localized lymphadenitis, pulmonary disease, systemic inflammation indistinguishable from active MAC
- MAC-IRIS patients are not bacteremic
- Cryptococcosis- worsening meningitis symptoms
- CMV- retinitis, vitritis, uveitis
- IRIS due to CMV can cause vision loss
- mean time to vitritis 20 weeks
- IRIS due to CMV can cause vision loss
- Hepatitis B or C- transient transaminitis difficult to distinguish from drug induced cause
- hepatic flares usually mild, may decompensate cirrhotics.
- Progressive multifocal leukoencephalopathy- worsening focal neuro lesions, changes on MRI
- Kaposi's Sarcoma- worsening Kaposi's
- Autoimmune diseases- Pre-existing autoimmune disorder exacerbation
Minor Presentations
- Herpes Simplex Virus and Varicella zoster virus reactivation
- Non-specific derm- many including oral and genital warts
Differential Diagnosis
- New infection not associated with IRIS (i.e. bacterial meningitis)
- Opportunistic infection
HIV associated conditions
- HIV neurologic complications
- HIV pulmonary complications
- Ophthalmologic complications
- Other
- HAART medication side effects[1]
- HAART-induced lactic acidosis
- Neuropyschiatric effects
- Hepatic toxicity
- Renal toxicity
- Steven-Johnson's
- Cytopenias
- GI symptoms
- Endocrine abnormalities
Evaluation
Management
Mild IRIS
- Standard therapy for offending opportunistic info (i.e. acyclovir for HSV)
- Largely supportive care
- NSAIDs for mild symptoms
- Inhaled steroids for pulmonary symptoms
- Continue ARV except in severe IRIS (see below)
Severe IRIS
- Defined as a threat to functional status or permanent disability (i.e. vision loss from CMV)
- Severe IRIS- prednisone 1-2mg/kg (consult HIV/ID) for 1-2 weeks then taper
Disposition
- Admit for severe IRIS.
- Dispo in conjunction with HIV/ID consult.
See Also
External Links
- www.hivguidelines.org
References
- ↑ Gutteridge, David L MD, MPH, Egan, Daniel J. MD. The HIV-Infected Adult Patient in The Emergency Department: The Changing Landscape of the Disease. Emergency Medicine Practice: An Evidence-Based Approach to Emergency Medicine. Vol 18, Num 2. Feb 2016.