Immune reconstitution inflammatory syndrome: Difference between revisions
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==Clinical Features== | ==Clinical Features== | ||
===Major Presentations=== | ===Major Presentations=== | ||
*TB- worsening TB symptoms | *[[TB]]- worsening TB symptoms | ||
*MAC- localized lymphadenitis, pulm disease, systemic inflammation indistinguishable from active MAC | *MAC- localized lymphadenitis, pulm disease, systemic inflammation indistinguishable from active MAC | ||
**MAC-IRIS patients are not bacteremic | **MAC-IRIS patients are not bacteremic | ||
* | *[[Cryptococcosis]]- worsening meningitis symptoms | ||
*CMV-Retinitis, Vitritis, Uveitis | *[[CMV]]-Retinitis, Vitritis, Uveitis | ||
**IRIS due to CMV can cause vision loss | **IRIS due to CMV can cause vision loss | ||
***mean time to vitritis 20 weeks | ***mean time to vitritis 20 weeks | ||
*Hepatitis B or C- transient transaminitis difficult to distinguish from drug induced cause | *[[Hepatitis]] B or C- transient transaminitis difficult to distinguish from drug induced cause | ||
**hepatic flares usually mild, may decompensate cirrhotics. | **hepatic flares usually mild, may decompensate cirrhotics. | ||
*Progressive Multifocal Leukoencephalopathy- worsening focal neuro lesions, changes on MRI | *Progressive Multifocal Leukoencephalopathy- worsening focal neuro lesions, changes on MRI | ||
*Kaposi's Sarcoma- worsening Kaposi's | *[[Kaposi's Sarcoma]]- worsening Kaposi's | ||
*Autoimmune diseases- Pre-existing autoimmune disorder exacerbation | *Autoimmune diseases- Pre-existing autoimmune disorder exacerbation | ||
===Minor Presentations=== | ===Minor Presentations=== | ||
*Herpes Simplex Virus and Varicella Zoster Virus reactivation | *[[Herpes Simplex Virus]] and [[Varicella Zoster Virus]] reactivation | ||
*Non-specific derm- many including oral and genital warts | *Non-specific derm- many including oral and genital warts | ||
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==Diagnosis== | ==Diagnosis== | ||
*Index of suspicion with known recent initiation of ARV's | *Index of suspicion with known recent initiation of ARV's | ||
*System specific testing (CXR, LP etc) | |||
==Management== | ==Management== | ||
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===Severe IRIS=== | ===Severe IRIS=== | ||
*Defined as a threat to functional status or permanent disability (i.e. vision loss from CMV) | *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 | *Severe IRIS- [[prednisone]] 1-2mg/kg (consult HIV/ID) for 1-2 weeks then taper | ||
==Disposition== | ==Disposition== | ||
In conjunction with HIV/ID and ability of patient to follow-up | |||
==See Also== | ==See Also== | ||
*[[HIV]] | |||
==External Links== | ==External Links== | ||
Revision as of 18:01, 31 July 2015
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, pulm 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
- Opportunistic infection based on H&P
Diagnosis
- Index of suspicion with known recent initiation of ARV's
- System specific testing (CXR, LP etc)
Management
Mild IRIS
- Standard therapy for offending opportunistic info (i.e. acyclovir for HSV)
- Largely supportive care
- NSAID's 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
In conjunction with HIV/ID and ability of patient to follow-up