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Abstract
HIV infection alters the skin microbiome and predisposes to a wide range of cutaneous infections, from atypical presentations of common skin infections to severe disseminated infections involving the skin that are AIDS-defining illnesses. Bacterial infection of the skin, most commonly caused by Staphylococcus aureus, occurs frequently and can result in bacteremia. Nontuberculous mycobacterial infections that are usually localized to the skin may disseminate, and guidance on the treatment of these infections is limited. Herpes simplex can be severe, and less common presentations such as herpetic sycosis and herpes vegetans have been reported. Severe herpes zoster, including disseminated infection, requires intravenous antiviral treatment. Viral warts can be particularly difficult to treat, and in atypical or treatment-resistant cases a biopsy should be considered. Superficial candidosis occurs very commonly in people living with HIV, and antifungal resistance is an increasing problem in non-albicans Candida species. Systemic infections carry a poor prognosis. In tropical settings the endemic mycoses including histoplasmosis are a problem for people living with HIV, and opportunistic infections can affect those with advanced HIV in all parts of the world. Most cutaneous infections can develop or worsen as a result of immune reconstitution in the weeks to months after starting antiretroviral therapy. Direct microscopic examination of clinical material can facilitate rapid diagnosis and treatment initiation, although culture is important to provide microbiological confirmation and guide treatment.
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Affiliation(s)
- David J Chandler
- Dermatology Department, University Hospitals Sussex NHS Foundation Trust, Brighton, UK; Department of Global Health & Infection, Brighton and Sussex Medical School, Brighton, UK.
| | - Stephen L Walker
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK; Hospital for Tropical Diseases and Department of Dermatology, University College London Hospitals NHS Foundation Trust, London, UK
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2
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Gra M, Blaizot R, Grotta G, Drak Alsibai K, Couppie P. Papules on the face after cART introduction: Demodicosis as an immune reconstitution inflammatory syndrome. J Eur Acad Dermatol Venereol 2024; 38:e177-e179. [PMID: 37728527 DOI: 10.1111/jdv.19519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 09/15/2023] [Indexed: 09/21/2023]
Affiliation(s)
- M Gra
- Dermatology Department, Cayenne Hospital Center, Cayenne, French Guiana
| | - R Blaizot
- Dermatology Department, Cayenne Hospital Center, Cayenne, French Guiana
- UMR 1019 Tropical Biomes and Immunophysiopathology (TBIP), Université de Cayenne, Cayenne, French Guiana
| | - G Grotta
- Dermatology Department, Cayenne Hospital Center, Cayenne, French Guiana
| | - K Drak Alsibai
- Department of Pathology and Center of Biological Resources (CRB Amazonie), Cayenne Hospital Center, Cayenne, French Guiana
| | - P Couppie
- Dermatology Department, Cayenne Hospital Center, Cayenne, French Guiana
- UMR 1019 Tropical Biomes and Immunophysiopathology (TBIP), Université de Cayenne, Cayenne, French Guiana
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3
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Chimbetete T, Buck C, Choshi P, Selim R, Pedretti S, Divito SJ, Phillips EJ, Lehloenya R, Peter J. HIV-Associated Immune Dysregulation in the Skin: A Crucible for Exaggerated Inflammation and Hypersensitivity. J Invest Dermatol 2023; 143:362-373. [PMID: 36549954 PMCID: PMC9974923 DOI: 10.1016/j.jid.2022.07.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 07/22/2022] [Accepted: 07/25/2022] [Indexed: 12/24/2022]
Abstract
Skin diseases are hallmarks of progressive HIV-related immunosuppression, with severe noninfectious inflammatory and hypersensitivity conditions as common as opportunistic infections. Conditions such as papular pruritic eruption are AIDS defining, whereas delayed immune-mediated adverse reactions, mostly cutaneous, occur up to 100-fold more during HIV infection. The skin, constantly in contact with the external environment, has a complex immunity. A dense, tightly junctioned barrier with basal keratinocytes and epidermal Langerhans cells with antimicrobial, innate-activating, and antigen-presenting functions form the frontline. Resident dermal dendritic, mast, macrophage, and innate lymphoid cells play pivotal roles in directing and polarizing appropriate adaptive immune responses and directing effector immune cell trafficking. Sustained viral replication leads to progressive declines in CD4 T cells, whereas Langerhans and dermal dendritic cells serve as viral reservoirs and points of first viral contact in the mucosa. Cutaneous cytokine responses and diminished lymphoid populations create a crucible for exaggerated inflammation and hypersensitivity. However, beyond histopathological description, these manifestations are poorly characterized. This review details normal skin immunology, changes associated with progressive HIV-related immunosuppression, and the characteristic conditions of immune dysregulation increased with HIV. We highlight the main research gaps and several novel tissue-directed strategies to define mechanisms that will provide targeted approaches to prevention or treatment.
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Affiliation(s)
- Tafadzwa Chimbetete
- Division of Allergology and Clinical Immunology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Chloe Buck
- Division of Allergology and Clinical Immunology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Phuti Choshi
- Division of Allergology and Clinical Immunology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Rose Selim
- Division of Allergology and Clinical Immunology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Sarah Pedretti
- Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Sherrie Jill Divito
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Rannakoe Lehloenya
- Division of Dermatology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa; Combined Drug Allergy Clinic, Groote Schuur Hospital, Cape Town, South Africa
| | - Jonny Peter
- Division of Allergology and Clinical Immunology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa; Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town, South Africa; Combined Drug Allergy Clinic, Groote Schuur Hospital, Cape Town, South Africa.
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Pourshahid S, Khademolhosseini S, Giri B, Cossio M, Rubio E. A Case of Steroid-Responsive Severe Pneumonia Following a Recent COVID-19 Infection in a Patient With Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infection. Cureus 2022; 14:e26785. [PMID: 35967156 PMCID: PMC9370069 DOI: 10.7759/cureus.26785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2022] [Indexed: 11/25/2022] Open
Abstract
A twenty-two-year-old woman with a history of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS) on rituximab presented with fever, abdominal pain, and worsening shortness of breath requiring supplemental oxygen via nasal cannula one month after a severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection from which she was minimally symptomatic and had recovered. Radiographic studies revealed bilateral patchy consolidations interspersed with ground-glass opacities (GGO). She was started on antibiotics for presumed community-acquired pneumonia with no improvement. Echocardiography revealed preserved biventricular function and a suspected intracardiac mass. A cardiac magnetic resonance imaging (CMRI) revealed myocarditis and no intracardiac mass. Fever persisted and oxygen requirements increased from FiO2 0.4 to 1.0. Repeat CXR showed subtotal left hemithorax opacification. Bronchoscopic samples showed a negative Gram stain and an unremarkable cell count differential. In view of this and given her lack of response to antibiotics with worsening respiratory status, high-dose steroids were started. She improved rapidly, and six days later she was off oxygen. Transbronchial biopsies showed benign parenchyma with some intra-alveolar fibrin deposition with no definitive evidence of viral cytopathic effect, vasculitis, or diffuse alveolar damage (DAD). Follow-up imaging in the pulmonary clinic revealed improvement of prior airspace disease with some new migratory opacities that completely resolved after 12 weeks. Pulmonary function tests and repeat CMRI were normal three months after discharge. Multisystem inflammatory syndrome in adults (MISA), post-covid organizing pneumonia (OP), and immune reconstitution inflammatory syndrome (IRIS) are rare and potentially steroid-responsive causes of pneumonia, which were in our differential diagnosis. It is imperative to consider the rare possibility of steroid-responsive pneumonia-like MISA, post-COVID-OP, and IRIS in patients with worsening respiratory symptoms following a recent SARS-CoV 2 infection.
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Demirbaş A, Çelik ZE. Jessner's lymphocytic infiltration as a symptom of Immune Reconstitution Inflammatory Syndrome in an HIV-infected patient: A case report. Dermatol Ther 2020; 33:e13637. [PMID: 32436645 DOI: 10.1111/dth.13637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/12/2020] [Accepted: 05/14/2020] [Indexed: 11/29/2022]
Affiliation(s)
| | - Zeliha Esin Çelik
- Department of Pathology, Faculty of Medicine, Selcuk University, Konya, Turkey
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Meyer D, Smit DP. Eyelid and Orbital Involvement in HIV Infection - An African Perspective. Ocul Immunol Inflamm 2020; 28:1022-1030. [PMID: 32058857 DOI: 10.1080/09273948.2019.1705987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Both infective and neoplastic eyelid and orbital conditions in human immunodeficiency virus (HIV) infected patients are often the result of opportunistic or co-infections (OI). In most cases, these clinical findings in younger patients alert the physician to suspected underlying HIV infection. When the eyelids and periorbital skin are primarily involved in OI with varicella-zoster virus it is called Herpes Zoster Ophthalmicus. Co-infection with a Pox virus manifests as molluscum contagiosum eruptions. Orbital cellulitis is secondary to various organisms (Mycobacterium tuberculosis, Candida albicans, Aspergillus). Neoplastic disorders are also often associated with OI such as human herpes virus 8 in Kaposi Sarcoma, Epstein-Barr virus in Hodgkin Lymphoma and human papillomavirus 16 and 18 in squamous cell carcinoma. In this review we share our personal clinical experience with HIV disease in Sub-Saharan Africa over more than two decades and provide photographs of cases to illustrate pertinent aspects of the conditions discussed.
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Affiliation(s)
- David Meyer
- Division of Ophthalmology, Faculty of Medicine and Health Sciences, Stellenbosch University , Cape Town, South Africa
| | - Derrick P Smit
- Division of Ophthalmology, Faculty of Medicine and Health Sciences, Stellenbosch University , Cape Town, South Africa
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Gupta A, Sharma YK, Ghogre M, Misra S, Pawar S. Giant molluscum contagiosum unmasked probably during an immune reconstitution inflammatory syndrome. Indian J Sex Transm Dis AIDS 2019; 39:139-140. [PMID: 30623189 PMCID: PMC6298148 DOI: 10.4103/ijstd.ijstd_60_16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Restoration of specific immune responses by combined antiretroviral therapy (cART) in patients infected with human immunodeficiency virus (HIV) may paradoxically cause an inflammatory reaction known as immune reconstitution inflammatory syndrome (IRIS). We report the emergence of giant nodules of molluscum contagiosum (MC) on the face and thighs 2 months after initiation of cART in a 45-year-old male patient with acquired immune deficiency syndrome. To the best of our knowledge, our report describes the first case of MC probably unmasked during IRIS from India.
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Affiliation(s)
- Aayush Gupta
- Department of Dermatology, Dr. D Y Patil Medical College and Hospital, Pune, Maharashtra, India
| | - Yugal Kishor Sharma
- Department of Dermatology, Dr. D Y Patil Medical College and Hospital, Pune, Maharashtra, India
| | - Manoj Ghogre
- Department of Dermatology, Dr. D Y Patil Medical College and Hospital, Pune, Maharashtra, India
| | - Shubhshree Misra
- Department of Dermatology, Dr. D Y Patil Medical College and Hospital, Pune, Maharashtra, India
| | - Shilpa Pawar
- Department of Dermatology, Dr. D Y Patil Medical College and Hospital, Pune, Maharashtra, India
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Ulcerative nodules on the perineum. ACTAS DERMO-SIFILIOGRAFICAS 2018. [DOI: 10.1016/j.adengl.2016.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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9
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Sueki H, Mizukawa Y, Aoyama Y. Immune reconstitution inflammatory syndrome in non-HIV immunosuppressed patients. J Dermatol 2017; 45:3-9. [PMID: 28944502 DOI: 10.1111/1346-8138.14074] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 08/29/2017] [Indexed: 12/17/2022]
Abstract
Immune reconstitution inflammatory syndrome (IRIS) represents a clinical phenomenon of immune-mediated inflammation against various antigens, including pathogenic microorganisms, drugs and unknown autoantigens, during recovery from immunosuppressed conditions. IRIS has become well recognized in HIV-infected populations. However, IRIS has seldom been recognized in HIV-negative immunocompromised patients. In the last 15 years, the immunopathogenesis of drug-induced hypersensitivity syndrome (DIHS) has been largely determined. Laboratory data and clinical observations support the idea that DIHS represents a prototype of non-HIV IRIS. Primary diseases in which non-HIV IRIS is secondary include severe cutaneous adverse drug reactions, such as DIHS, autoimmune diseases, collagen diseases, pregnancy and internal malignancies. Potential triggers of recovery from an immune deterioration state include a discontinuation or abrupt tapering of systemic steroids and/or immunosuppressants, withdrawal or reduced effects of anti-tumor necrosis factor-α antibodies, and the use of immune-checkpoint antagonists for the advanced stages of malignancies. Wide use of IRIS across large populations risks oversimplification but highlights a key unifying principle. Balanced sensitivity and specificity for its diagnostic criteria and classification are necessary for the establishment of clinical practice guidelines for non-HIV IRIS. Additionally, the development of a useful combination of biomarkers is currently an urgent issue.
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Affiliation(s)
- Hirohiko Sueki
- Department of Dermatology, School of Medicine, Showa University, Tokyo, Japan
| | - Yoshiko Mizukawa
- Department of Dermatology, School of Medicine, Kyorin University, Tokyo, Japan
| | - Yumi Aoyama
- Department of Dermatology, School of Medicine, Kawasaki Medical University, Okayama, Japan
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10
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Ulcerative nodules on the perineum. ACTAS DERMO-SIFILIOGRAFICAS 2017; 109:355-356. [PMID: 28495128 DOI: 10.1016/j.ad.2016.11.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Revised: 11/03/2016] [Accepted: 11/06/2016] [Indexed: 11/23/2022] Open
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11
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Nelson AM, Manabe YC, Lucas SB. Immune Reconstitution Inflammatory Syndrome (IRIS): What pathologists should know. Semin Diagn Pathol 2017; 34:340-351. [PMID: 28552210 DOI: 10.1053/j.semdp.2017.04.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Antiretroviral therapy has significantly improved the quality and length of life for those patients able to access effective and sustained treatment. The resulting restoration of the immune response is associated with a change in the clinical presentation of opportunistic infections, and the histologic reaction to pathogens. A complex combination of alterations in host response across the stages of HIV infection has been documented over the past 3 decades. The defects are seen in both acute and chronic phases of inflammation and involve innate and adaptive immunity. In advanced stages of HIV infection, the marked disruption of lymphoid tissue and loss of follicular dendritic cells limits the host's ability to process antigen and mount specific responses to pathogens. There are qualitative and quantitative defects in CD4 T cells due to HIV infection. The resulting indirect effects include loss of cytokine production, dysregulation of B-cell function, loss of cellular mediated immunity and "holes" in the immunologic repertoire that may not be restored with the use of antiretroviral therapy. Immune reconstitution allows the host to respond to and control infection, but a significant number of patients will have atypical inflammatory syndromes during the recovery period. We briefly discuss the impact of HIV infection on the immune system and give an overview of the spectrum of conditions attributed to the Immune Reconstitution Inflammatory syndrome (IRIS).
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12
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Rigi M, Khan K, Smith SV, Suleiman AO, Lee AG. Evaluation and management of the swollen optic disk in cryptococcal meningitis. Surv Ophthalmol 2017; 62:150-160. [DOI: 10.1016/j.survophthal.2016.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 10/02/2016] [Accepted: 10/10/2016] [Indexed: 12/20/2022]
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Uddhao Z, Aditi C, Chitra N, Swagata T. A rare occurrence of epidermolysis bullosa acquisita in a patient with retroviral disease. Int J STD AIDS 2017. [PMID: 28632473 DOI: 10.1177/0956462417696433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Epidermolysis bullosa acquisita is a chronic subepidermal blistering disease associated with autoimmunity to type-VII collagen within anchoring fibrils located at the dermo-epidermal junction. This entity is rarely reported from India. It can have a variety of presentations. Its occurrence with retroviral disease has rarely been reported. Here, we present a case of epidermolysis bullosa acquisita in a patient with HIV infection.
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Affiliation(s)
- Zambare Uddhao
- Department of Dermatology, Topiwala National Medical College & B.Y.L. Nair Ch. Hospital, Mumbai, India
| | - Chhonkar Aditi
- Department of Dermatology, Topiwala National Medical College & B.Y.L. Nair Ch. Hospital, Mumbai, India
| | - Nayak Chitra
- Department of Dermatology, Topiwala National Medical College & B.Y.L. Nair Ch. Hospital, Mumbai, India
| | - Tambe Swagata
- Department of Dermatology, Topiwala National Medical College & B.Y.L. Nair Ch. Hospital, Mumbai, India
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Erythema Nodosum Leprosum-Like Lesions Are a Histopathologic Pattern in Whipple's Disease and a Sign of the Immune Reconstitution Inflammatory Syndrome: A Case Series and Review of the Literature. Am J Dermatopathol 2017; 39:259-266. [PMID: 28098596 DOI: 10.1097/dad.0000000000000641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Inflammatory and subcutaneous nodules can arise in treated and untreated cases of Whipple disease (WD). The inflammatory immune reconstitution syndrome describes paradoxical clinical inflammatory worsening of a preexisting condition because of a return of immune function. Clinicopathologic examination of 4 patients with WD who presented with erythema nodosum leprosum (ENL)-like lesions and the findings of a systematic review of this phenomenon revealed that ENL-like lesions occurred in predominantly middle-aged male patients who suffered from WD, mostly on the legs. Patients showed a nonvasculitic, mostly septal panniculits with neutrophils, macrophages, and lymphocytes. Numerous bacteria-laden periodic acid-Schiff + macrophages and free bacilli were detected in the dermis, as well as subcutaneous septae and adipose lobules. These lesions occurred in both untreated and treated patients as part of inflammatory immune reconstitution syndrome. In conclusion, ENL-like lesions represent a characteristic histopathologic pattern associated with WD, which can occur in different contexts whenever there is a change in the immunological status of the patient. This change can be triggered by antimicrobial treatment, immunomodulatory and immunosuppressant therapy, or occur spontaneously, rarely.
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French MA, Meintjes G. Immune Reconstitution Disorders in Patients with HIV Infection. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00095-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Kiggundu R, Nabeta HW, Okia R, Rhein J, Lukande R. Unmasking histoplasmosis immune reconstitution inflammatory syndrome in a patient recently started on antiretroviral therapy. AUTOPSY AND CASE REPORTS 2016; 6:27-33. [PMID: 28210571 PMCID: PMC5304559 DOI: 10.4322/acr.2016.048] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 09/09/2016] [Indexed: 11/23/2022] Open
Abstract
Histoplasmosis is the most common endemic mycoses among HIV-infected people. Patients with suppressed cell immunity mainly due to HIV are at increased risk of disseminated disease. Dermatological manifestations of immune reconstitution inflammatory syndrome (IRIS) and cutaneous manifestations of histoplasmosis similar to an IRIS event have been previously described. We report the case of a 43-year-old male who presented with cutaneous disseminated histoplasmosis due to Histoplasma capsulatum var. capsulatum 4 months after the onset of the antiretroviral therapy and some improvement in the immune reconstitution. After 2 weeks of amphotericin B and itraconazole therapy, the scheduled treatment involved fluconazole maintenance therapy, which resulted in an improvement of his skin lesions.
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Affiliation(s)
- Reuben Kiggundu
- College of Health Sciences - Infectious Disease Institute - Makerere University, Kampala - Uganda
| | - Henry W Nabeta
- College of Health Sciences - School of Medicine - Makerere University, Kampala - Uganda
| | - Richard Okia
- College of Health Sciences - School of Medicine - Makerere University, Kampala - Uganda
| | - Joshua Rhein
- College of Health Sciences - Infectious Disease Institute - Makerere University, Kampala - Uganda.; Department of Medicine - University of Minnesota, Minneapolis/MN - USA
| | - Robert Lukande
- College of Health Sciences - School of Biomedical Sciences - Makerere University, Kampala - Uganda
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18
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Immune reconstitution inflammatory syndrome in an HIV-infected patient using subcutaneous silicone fillers. AIDS 2016; 30:2561-2563. [PMID: 27536984 DOI: 10.1097/qad.0000000000001239] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The immune reconstitution inflammatory syndrome (IRIS) remains a concern in severely immunosuppressed HIV-infected patients after starting antiretroviral therapy. We present an HIV-infected transgender woman with subcutaneous silicone fillers, who simultaneously developed tuberculosis-associated and silicone-related IRIS. We propose a possible connection between IRIS and the autoimmune/inflammatory syndrome induced by adjuvants (ASIA).
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19
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Gamba CS, Lambert Smith F, Wisell J, Brown M. Tattoo reactions in an HIV patient: Autoeczematization and progressive allergic reaction to red ink after antiretroviral therapy initiation. JAAD Case Rep 2016; 1:395-8. [PMID: 27051791 PMCID: PMC4809398 DOI: 10.1016/j.jdcr.2015.09.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Christina S Gamba
- Department of Dermatology, Stanford University School of Medicine, Stanford, California
| | - Franki Lambert Smith
- Department of Dermatology, University of Colorado School of Medicine, Aurora, Colorado
| | - Josh Wisell
- Department of Pathology, University of Colorado School of Medicine, Aurora, Colorado
| | - Mariah Brown
- Department of Dermatology, University of Colorado School of Medicine, Aurora, Colorado
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Rachadi H, Ramli I, Meknassi I, Hassam B, Benzekri L. [Recurrence of cutaneous sarcoidosis during immune reconstitution syndrome in an HIV-infected patient]. Ann Dermatol Venereol 2015; 142:757-60. [PMID: 26616022 DOI: 10.1016/j.annder.2015.10.583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 05/07/2015] [Accepted: 10/02/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Association of sarcoidosis and HIV can occur in the context of immune reconstitution syndrome (IRS) after initiation of antiretroviral therapy (ART). Herein we report a case of cutaneous sarcoidosis in remission in an HIV-infected patient but relapsing during IRS associated with initiation of ART. PATIENTS AND METHODS A 33-year-old female HIV-infected patient from Cameroon was treated with triple therapy with good efficacy. The patient previously had a small nodular lesion on her left cheek which disappeared spontaneously 2 months before the diagnosis of HIV infection. Three months after initiation of triple ART, the patient consulted again for recurrence of the lesion, which had gradually increased in size. Clinical examination revealed a purplish-red nodular plaque of lupoid appearance under vitropression, located between the inner corner of the eye, the nasal wing and the left cheek. A skin biopsy revealed giant-cell epithelioid dermal granulomas without caseous necrosis. Blood angiotensin-converting enzyme levels were elevated and intradermal reaction to tuberculin was negative. A diagnosis was made of cutaneous sarcoidosis. The patient was treated with chloroquine 200mg/day for 3 months, resulting in total subsidence of the lesions. No recurrence was observed at 1 year. DISCUSSION Introduction of ART has changed the dermatological aspect of HIV infection. In addition to specific dermatological signs specific to HIV and to immunosuppression, there are the cutaneous adverse effects of antiretroviral drugs and skin disorders indicating reconstituted immunity during IRS. Schematically, three forms of IRS may be distinguished: the paradoxical form, the infectious form, and the inflammatory form. The latter corresponds to the onset or exacerbation of inflammatory conditions or autoimmune diseases after the start of ART. Thirty cases of association between sarcoidosis and HIV have been described, of which two-thirds occurred during IRS. The central role of CD4 in sarcoidosis explains its occurrence in HIV patients during reconstitution of the CD4 count. CONCLUSION In HIV-infected patients treated with anti-retroviral treatment, certain skin diseases such as sarcoidosis may be related to IRS.
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Affiliation(s)
- H Rachadi
- Service de dermatologie-vénéréologie, CHU Ibn Sina, faculté de médecine et de pharmacie, université Mohamed V, Rabat, Maroc.
| | - I Ramli
- Service de dermatologie-vénéréologie, CHU Ibn Sina, faculté de médecine et de pharmacie, université Mohamed V, Rabat, Maroc
| | - I Meknassi
- Service de dermatologie-vénéréologie, CHU Ibn Sina, faculté de médecine et de pharmacie, université Mohamed V, Rabat, Maroc
| | - B Hassam
- Service de dermatologie-vénéréologie, CHU Ibn Sina, faculté de médecine et de pharmacie, université Mohamed V, Rabat, Maroc
| | - L Benzekri
- Service de dermatologie-vénéréologie, CHU Ibn Sina, faculté de médecine et de pharmacie, université Mohamed V, Rabat, Maroc
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Vora RV, Pilani AP, Kota RK. Extensive Giant Molluscum Contagiosum in a HIV Positive Patient. J Clin Diagn Res 2015; 9:WD01-2. [PMID: 26672647 DOI: 10.7860/jcdr/2015/15107.6797] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 09/27/2015] [Indexed: 11/24/2022]
Abstract
Molluscum contagiosum (MC) is a very common benign self-limiting cutaneous viral infection caused by molluscum contagiosum virus. Disease is self-limiting in immunocompetent individuals, while it is severe and prolonged when associated with Human Immunodeficiency Virus (HIV) infection. The widespread and refractory mollusca of HIV disease occur especially on the face. In advanced stages of immunosuppression, giant or verrucous forms of MC may occur. Molluscum contagiosum tends to take a chronic course and is usually not responsive to various treatments in immunocompromised patients. Here, we present a HIV positive male patient with extensive papulonodular lesions over face, neck, bilateral upper limbs since 2 months, diagnosed as giant molluscum contagiosum, treated with cryotherapy with little improvement for few weeks after which patient did not turn up.
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Affiliation(s)
- Rita V Vora
- Professor and Head, Department of Dermatology, Shree Krishna Hospital, Pramukh Swami Medical College , Karamsad, Gujarat, India
| | - Abhishek P Pilani
- Ex-Resident, Department of Dermatology, Shree Krishna Hospital, Pramukh Swami Medical College , Karamsad, Gujarat, India
| | - Rahul Krishna Kota
- Resident, Department of Dermatology, Shree Krishna Hospital, Pramukh Swami Medical College , Karamsad, Gujarat, India
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Psoriasis as a manifestation of HIV-related immune reconstitution inflammatory syndrome. J Am Acad Dermatol 2015; 72:e35-6. [DOI: 10.1016/j.jaad.2014.09.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 09/09/2014] [Accepted: 09/15/2014] [Indexed: 11/19/2022]
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Cota C, Latini A, Lora V, Cerroni L. Mid-dermal elastolysis as a manifestation of immune reconstitution inflammatory syndrome in an HIV-infected patient. J Am Acad Dermatol 2014; 71:e134-5. [PMID: 25219731 DOI: 10.1016/j.jaad.2014.04.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 04/17/2014] [Indexed: 12/01/2022]
Affiliation(s)
- Carlo Cota
- Dermatopathology Unit, San Gallicano Dermatological Institute, Rome, Italy.
| | - Alessandra Latini
- Division of Dermatology, San Gallicano Dermatological Institute, Rome, Italy
| | - Viviana Lora
- Division of Dermatology, San Gallicano Dermatological Institute, Rome, Italy
| | - Lorenzo Cerroni
- Dermatopathology Research Unit, Department of Dermatology, Medical University of Graz, Austria
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Liu C, Wang C, Glesby MJ, D’souza G, French A, Minkoff H, Maurer T, Karim R, Young M. Effects of highly active antiretroviral therapy and its adherence on herpes zoster incidence: a longitudinal cohort study. AIDS Res Ther 2013; 10:34. [PMID: 24373482 PMCID: PMC3904465 DOI: 10.1186/1742-6405-10-34] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 12/13/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Herpes zoster (HZ) is common among HIV-infected individuals, but the impacts of highly active antiretroviral therapy (HAART) and HAART adherence on HZ risk have not been well studied. METHODS The effects of HAART and HAART adherence on HZ incidence were evaluated by comparing HIV-infected women on HAART (HAART use group) with the HIV-infected women remaining HAART naïve (HAART naïve group) in the Women's Interagency HIV Study (WIHS). A 1:1 matching with propensity score for predicting HAART initiation was conducted to balance background covariates at index visit, including HIV disease stage. Kaplan-Meier method was used to compare the risk of HZ development between the matched pairs. Cox proportional hazard models were used to assess the effects of HAART and HAART adherence on HZ incidence. RESULTS Through propensity score matching, 389 pairs of participants were identified and they contributed 3,909 person years after matching. The background covariates were similar between the matched pairs at the index visit. The participants had a mean age around 39 years old, and about 61% of them were Black and 22% were Latina. No significant difference in HZ risk was observed between the HAART use group and the HAART naïve group during the first year of follow-up in any analyses. In the univariate analysis, the HAART use group had marginally lower HZ risk (Hazard Ratio (HR): 0.72; 95% Confidence Interval (CI): 0.48-1.1) over the entire follow-up period. However, women with a HAART adherence level of ≥95% had significantly lower HZ risk (HR: 0.54; 95% CI: 0.31, 0.94) compared to the HAART naïve women. The association remained significant after adjusting for quality of life score and acyclovir use, but it attenuated and was no longer statistically significant after adjusting for an intermediate variable, either CD4+ T cell counts or HIV viral load. CONCLUSIONS Among adult women, we observed a significant preventive effect of long-term HAART use on HZ incidence when a HAART adherence level of ≥95% was attained, and this effect was mediated through reduction of HIV viral load and improvement of CD4+ T cell counts.
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Affiliation(s)
- Chenglong Liu
- Department of Medicine, Georgetown University, 2115 Wisconsin Avenue NW, Suite 130, Washington, DC 20007, USA
| | - Cuiwei Wang
- Department of Medicine, Georgetown University, 2115 Wisconsin Avenue NW, Suite 130, Washington, DC 20007, USA
| | - Marshall J Glesby
- Division of Infectious Diseases, Weill Cornell Medical College, New York, NY, USA
| | - Gypsyamber D’souza
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Audrey French
- Division of Infectious Diseases, Cook County Hospital, Chicago, lL, USA
| | - Howard Minkoff
- Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NY, USA
| | - Toby Maurer
- Department of Dermatology, University of California at San Francisco, San Francisco, CA, USA
| | - Roksana Karim
- Departments of Pediatrics and Preventive Medicine, University of Southern California, Los Angeles, CA, USA
| | - Mary Young
- Department of Medicine, Georgetown University, 2115 Wisconsin Avenue NW, Suite 130, Washington, DC 20007, USA
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Abstract
Sub-Saharan Africa is the epicenter of the HIV pandemic and HIV-infected people are more susceptible to inflammatory dermatoses, infections, and drug eruptions. Many of the drugs used for HIV-associated opportunistic infections are associated with a higher incidence of drug-related toxicities and drug interactions. This article discusses the epidemiology, pharmacogenetics, and clinical features of idiosyncratic drug reactions in HIV-infected Africans. Special considerations in this population, including immune reconstitution inflammatory syndrome, multiple drug hypersensitivity syndrome, drug reactions in pregnancy, drug rechallenge in lichenoid drug eruptions, and anxiety/depression after cutaneous adverse drug reactions, are also briefly discussed.
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Drain PK, Mosam A, Gounder L, Gosnell B, Manzini T, Moosa MYS. Recurrent giant molluscum contagiosum immune reconstitution inflammatory syndrome (IRIS) after initiation of antiretroviral therapy in an HIV-infected man. Int J STD AIDS 2013; 25:235-8. [PMID: 23970647 DOI: 10.1177/0956462413497702] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We describe an HIV-infected South African man who experienced two distinct episodes of disseminated giant molluscum contagiosum immune reconstitution inflammatory syndrome (IRIS) over a six-year period. The first episode of molluscum contagiosum IRIS occurred with rapid virologic suppression following antiretroviral therapy initiation. The second episode occurred during a rapid increase in CD4 cells following stable viral suppression with second-line antiretroviral therapy. His molluscum contagiosum lesions then completely resolved during a reduction in CD4 count, despite maintaining virologic suppression. Nearly one year after the resolution of his giant molluscum contagiosum IRIS lesions, he maintains an undetectable viral load, but his level of immune deficiency has not improved. In the absence of well-controlled therapeutic trials, molluscum contagiosum IRIS presents important management challenges.
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Affiliation(s)
- Paul K Drain
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
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Short- and long-term outcomes of 34 patients with drug-induced hypersensitivity syndrome in a single institution. J Am Acad Dermatol 2013. [DOI: 10.1016/j.jaad.2012.10.017] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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New Insights into HIV/AIDS-Associated Cryptococcosis. ISRN AIDS 2013; 2013:471363. [PMID: 24052889 PMCID: PMC3767198 DOI: 10.1155/2013/471363] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 01/10/2013] [Indexed: 12/27/2022]
Abstract
Cryptococcal meningitis is a life-threatening opportunistic fungal infection in both HIV-infected and HIV-uninfected patients. According to the most recent taxonomy, the responsible fungus is classified into a complex that contains two species (Cryptococcus neoformans and C. gattii), with eight major molecular types. HIV infection is recognized worldwide as the main underlying disease responsible for the development of cryptococcal meningitis (accounting for 80-90% of cases). In several areas of sub-Saharan Africa with the highest HIV prevalence despite the recent expansion of antiretroviral (ARV) therapy programme, cryptococcal meningitis is the leading cause of community-acquired meningitis with a high mortality burden. Although cryptococcal meningitis should be considered a neglected disease, a large body of knowledge has been developed by several studies performed in recent years. This paper will focus especially on new clinical aspects such as immune reconstitution inflammatory syndrome, advances on management, and strategies for the prevention of clinical disease.
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Armstrong WS. The immune reconstitution inflammatory syndrome: a clinical update. Curr Infect Dis Rep 2013; 15:39-45. [PMID: 23224580 DOI: 10.1007/s11908-012-0308-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The immune reconstitution inflammatory syndrome (IRIS) is a well-described phenomenon in HIV-infected patients following initiation of antiretroviral therapy and can lead to significant morbidity and mortality in some patients. Risk for IRIS is enhanced in those with low CD4 counts and preexisting opportunistic infections. The development of pathogen-specific definitions of IRIS has aided classification of patients and has facilitated research. Newer data on optimal timing of ART initiation, with additional data in the setting of tuberculosis and cryptococcal meningitis, will help guide strategies to decrease the risk of IRIS but must balance the risks of HIV disease progression. Managing patients with IRIS can be challenging. Treatment options include pathogen-specific therapy, antiinflammatory therapies, and other novel approaches.
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Affiliation(s)
- Wendy S Armstrong
- Division of Infectious Disease, Emory University School of Medicine, 341 Ponce de Leon Ave, Atlanta, GA, 30308, USA,
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31
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Samson JF, Suja V, Samad KA, Sankar S, Libu GK. Immune reconstitution inflammatory syndrome: A therapeutic paradox. Indian Dermatol Online J 2012. [PMID: 23189257 PMCID: PMC3505432 DOI: 10.4103/2229-5178.101822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
A 41-year-old HIV positive woman was started on highly active antiretroviral therapy when her CD4 count was 54/cu mm. Three weeks later, she developed erythematous to skin-colored plaques over the face. Investigations revealed a moderate eosinophilia, raised ESR, elevated 24-hour urinary calcium and hyperglobulinemia. Skin biopsy of the facial plaque revealed prominent epithelioid cell granulomas in the dermis. Reticulin stain showed reticulin fibers within the granulomas. Five months later, all the facial lesions regressed with continuation of HAART, with no specific treatment for facial plaques. Repeat CD4 count was 104/cu mm. A diagnosis of cutaneous sarcoidosis occurring as a part of immune reconstitution inflammatory syndrome was made. Although systemic sarcoidosis has been reported, the occurrence of cutaneous sarcoidosis as part of immune reconstitution inflammatory syndrome has not been elucidated conclusively.
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Affiliation(s)
- Joan Felicita Samson
- Department of Dermatology and Venereology, Dr. S.M.C.S.I. Medical College, Karakonam, Thiruvananthapuram, Kerala, India
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Meintjes G, Scriven J, Marais S. Management of the immune reconstitution inflammatory syndrome. Curr HIV/AIDS Rep 2012; 9:238-50. [PMID: 22752438 DOI: 10.1007/s11904-012-0129-5] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The immune reconstitution inflammatory syndrome (IRIS) is a frequent early complication of antiretroviral therapy (ART) in patients with advanced HIV. Because there is no confirmatory diagnostic test, the diagnosis is based on clinical presentation and exclusion of alternative causes for deterioration, such as antimicrobial drug resistance. Opportunistic infection treatment should be optimized. Mild cases may require symptomatic therapy alone or nonsteroidal anti-inflammatory drugs. Corticosteroids have been used to treat more severe cases of IRIS associated with mycobacterial and fungal infections. There is evidence from a randomized controlled trial that prednisone reduces morbidity and improves symptoms in paradoxical tuberculosis (TB)-IRIS. Neurological TB-IRIS is potentially life-threatening; high-dose corticosteroids are indicated and ART interruption should be considered if level of consciousness is depressed. When considering corticosteroid treatment clinicians should be aware of their side effects and only use them when the diagnosis of IRIS is certain. In viral forms of IRIS corticosteroids are generally avoided.
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Affiliation(s)
- Graeme Meintjes
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
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Abstract
OBJECTIVE To describe incidence of immune reconstitution inflammatory syndrome (IRIS) and its association with mortality in a large multisite US HIV-infected cohort applying an objective, comprehensive definition. DESIGN We studied 2,610 patients seen during 1996-2007 who initiated or resumed highly active combination antiretroviral therapy (cART) and, during the next 6 months, demonstrated a decline in plasma HIV-RNA viral load of at least 0.5 log(10) copies/ml or an increase of at least 50% in CD4 cell count per microliter. We defined IRIS as the diagnosis of a type B or C condition [as per the Centers for Disease Control and Prevention (CDC) 1993 AIDS case definition] or any new mucocutaneous disorder during this same 6-month period. METHODS We assessed the incidence of IRIS and evaluated risk factors for IRIS using conditional logistic regression and for all-cause mortality using proportional hazards models. RESULTS We identified 370 cases of IRIS (in 276 patients). Median and nadir CD4 cell counts at cART initiation were 90 and 43 cells/μl, respectively; median viral load was 2.7 log(10) copies/ml. The most common IRIS-defining diagnoses were candidiasis (all forms), cytomegalovirus infection, disseminated Mycobacterium avium intracellulare, Pneumocystis pneumonia, varicella zoster, Kaposi's sarcoma and non-Hodgkin lymphoma. Only one case of Mycobacterium tuberculosis was observed. IRIS was independently associated with CD4 cell count less than 50 cells/μl vs. at least 200 cells/μl [odds ratio (OR) 5.0] and a viral load of at least 5.0 log(10) copies vs. less than 4.0 log(10) copies (OR 2.3). IRIS with a type B-defining or type C-defining diagnosis approximately doubled the risk for all-cause mortality. CONCLUSION In this large US-based HIV-infected cohort, IRIS occurred in 10.6% of patients who responded to effective ART and contributed to increased mortality.
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Nachega JB, Morroni C, Chaisson RE, Goliath R, Efron A, Ram M, Maartens G. Impact of immune reconstitution inflammatory syndrome on antiretroviral therapy adherence. Patient Prefer Adherence 2012; 6:887-91. [PMID: 23271897 PMCID: PMC3526885 DOI: 10.2147/ppa.s38897] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE We determined the impact of immune reconstitution inflammatory syndrome (IRIS) on antiretroviral therapy (ART) adherence in a cohort of 274 human immunodeficiency virus (HIV)-infected South African adults initiating ART. METHODS We carried out a secondary analysis of data from a randomized controlled trial of partially supervised ART in Cape Town, South Africa. Monthly pill count adherence, viral suppression (HIV viral load < 50 c/mL), and IRIS events were documented. Poisson regression was used to identify variables associated with ART adherence below the median in the first 6 months of ART. RESULTS We enrolled 274 patients: 58% women, median age 34 years, median CD4 count 98 cells/μL, 46% World Health Organization clinical stage IV, and 40% on treatment for tuberculosis (TB). IRIS and TB-IRIS developed in 8.4% and 6.6% of patients, respectively. The median cumulative adherence at 6 months for those with an IRIS event vs no IRIS was 95.5% vs 98.2% (P = 0.04). Although not statistically significant, patients developing IRIS had a lower 6-month viral load suppression than those without IRIS (68% vs 80%, P = 0.32). ART adherence below the median of 98% was independently associated with alcohol abuse (relative risk [RR] 1.5; 95% confidence interval [CI] 1.2-1.9; P = 0.003) and IRIS events (RR 1.7; 95% CI 1.2-2.2; P = 0.001). CONCLUSION Although IRIS events were associated with slightly lower adherence rates, overall adherence to ART remained high in this study population. Concerns about IRIS should not deter clinicians from early ART initiation.
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Affiliation(s)
- Jean B Nachega
- University of Cape Town, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
- Johns Hopkins University, Bloomberg School of Public Health, Departments of International Health and Epidemiology, Baltimore, Maryland, USA
- Johns Hopkins University, Center for Tuberculosis Research, Baltimore, Maryland, USA
- Correspondence: Jean B Nachega, Johns Hopkins University, Bloomberg School of Public Health, Department of International Health, Global Disease Epidemiology and Control Program, 615 N Wolfe Street, Suite W5031, Baltimore, MD 21205, USA, Tel +1 410 955 2378, Fax +1 410 502 6733, Email
| | - Chelsea Morroni
- University of Cape Town, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
| | - Richard E Chaisson
- Johns Hopkins University, Bloomberg School of Public Health, Departments of International Health and Epidemiology, Baltimore, Maryland, USA
- Johns Hopkins University, School of Medicine, Department of Medicine, Division of Infectious Diseases, Baltimore, Maryland, USA
- Johns Hopkins University, Center for Tuberculosis Research, Baltimore, Maryland, USA
| | - Rene Goliath
- University of Cape Town, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
| | - Anne Efron
- Johns Hopkins University, Center for Tuberculosis Research, Baltimore, Maryland, USA
| | - Malathi Ram
- Johns Hopkins University, Bloomberg School of Public Health, Departments of International Health and Epidemiology, Baltimore, Maryland, USA
| | - Gary Maartens
- University of Cape Town, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
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Passos L, Talhari C, Santos M, Ribeiro-Rodrigues R, Ferreira LCDL, Talhari S. Síndrome de restauração imune associada à histoplasmose. An Bras Dermatol 2011; 86:S168-72. [DOI: 10.1590/s0365-05962011000700044] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Accepted: 11/25/2010] [Indexed: 11/21/2022] Open
Abstract
Paciente masculino, 27 anos, portador de HIV, com quadro de histoplasmose cutânea disseminada. Terapia antirretroviral oral e anfotericina B por via EV (dose total acumulada 0,5g) foram introduzidas, verificando-se rápida cicatrização das lesões após duas semanas. A anfotericina B foi substituída por itraconazol (200mg/dia). O paciente interrompeu voluntariamente os tratamentos. A terapia antirretroviral foi reintroduzida, havendo aumento da contagem de células T CD4-positivas (No restante do texto, a autora usa o símbolo "+" (T CD4+) ao invés da palavra "positiva". O que fazer neste caso? Seguimos o padrão do restante do texto ou acatamos essa opção da autora no resumo?!). Neste momento, diagnosticou-se histoplasmose ganglionar. O aumento da contagem de células T CD4-positivas (de novo aqui), associado à redução da carga viral a níveis inferiores ao limite de detecção após a reintrodução da terapia antirretroviral, sugere que essa piora clínica paradoxal seja uma síndrome de restauração imune
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Affiliation(s)
- Leny Passos
- Fundação de Hematologia e Hemoterapia do Amazonas, Brasil
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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] [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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Ranu H, Lee J, Chio M, Sen P. Tumour-like presentations of anogenital herpes simplex in HIV-positive patients. Int J STD AIDS 2011; 22:181-6. [DOI: 10.1258/ijsa.2010.010204] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Genital and perianal ulcers seen in patients with HIV are commonly due to herpes simplex virus (HSV) infection. While it is well known that the characteristic presentation of HSV is a vesicular rash or crops of erosions, the clinical presentation of genital HSV infection in HIV is varied and can assume vegetative, hypertrophic, condyloma-like, nodular, ulcerative and tumour-like nodules or plaques. These unusual presentations often lead to a delayed diagnosis. We describe five immunocompromised HIV-positive patients with CD4 counts ranging from 114 to 326 cells/μL with unusual presentations of anogenital herpes.
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Affiliation(s)
- H Ranu
- National Skin Center, Singapore, Singapore
| | - J Lee
- National Skin Center, Singapore, Singapore
| | - M Chio
- National Skin Center, Singapore, Singapore
| | - P Sen
- National Skin Center, Singapore, Singapore
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Abstract
Immune reconstitution inflammatory syndrome (IRIS) is a phenomenon observed in patients recovering from immunodeficiency. The clinical presentation of IRIS involves the unmasking of covert infections or the worsening of overt conditions. Several causes and pathways have been suggested, most recognizing an inflammatory flare component occurring in the context of rapid immune reconstitution. In HIV-infected patients, IRIS inadvertently occurs as the consequence of successful antiretroviral therapy, and it is affiliated with improvement of the immune function, complicating the course of the disease and presenting treatment challenges to clinicians. The pathogenesis of IRIS is poorly understood, but in recovering HIV patients, its initiation and progression seem to be primarily linked to an increase in CD4+ T-helper and CD8+ T-suppressor cell count and a reduction in T-regulatory cells, all endorsed by exaggerated cytokine release and activity. The clinical presentation of IRIS is usually atypical. The manifestations depend on the trigger antigen, which can be an infective agent (viable or nonviable), a host antigen, or a tumor antigen. Most IRIS cases are self-limiting, but a few cases can be overwhelming and life-threatening; hence, early recognition is important. In most cases, there is no need to discontinue the antiretroviral therapy, although in the more severe cases, other clinical intervention may be necessary.
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Affiliation(s)
- A.R. Tappuni
- Institute of Dentistry, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, UK
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Letang E, Miró JM, Nhampossa T, Ayala E, Gascon J, Menéndez C, Alonso PL, Naniche D. Incidence and predictors of immune reconstitution inflammatory syndrome in a rural area of Mozambique. PLoS One 2011; 6:e16946. [PMID: 21386993 PMCID: PMC3046140 DOI: 10.1371/journal.pone.0016946] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Accepted: 01/18/2011] [Indexed: 11/18/2022] Open
Abstract
Background There is limited data on the epidemiology of Immune Reconstitution Inflammatory Syndrome (IRIS) in rural sub-Saharan Africa. A prospective observational cohort study was conducted to assess the incidence, clinical characteristics, outcome and predictors of IRIS in rural Mozambique. Methods One hundred and thirty-six consecutive antiretroviral treatment (ART)-naïve HIV-1-infected patients initiating ART at the Manhiça district hospital were prospectively followed for development of IRIS over 16 months. Survival analysis by Cox regression was performed to identify pre-ART predictors of IRIS development. Results Thirty-six patients developed IRIS [26.5%, incidence rate 3.1 cases/100 persons-month of ART (95% CI 2.2–4.3)]. Median time to IRIS onset was 62 days from ART initiation (IQR 35.5–93.5). Twenty-five cases (69.4%) were “unmasking”, 10 (27.8%) were “paradoxical”, and 1 (2.8%) developed a paradoxical worsening followed by the unmasking of another condition. Systemic OI (OI-IRIS) accounted for 47% (17/36) of IRIS cases, predominantly of KS (8 cases) and TB (6 cases) IRIS. Mucocutaneous IRIS manifestations (MC-IRIS) accounted for 53% (19/36) of IRIS events, mostly tinea (9 cases) and herpes simplex infection (3 cases). Multivariate analysis identified two independent predictors of IRIS development: pre-ART CD4 count <50 cells/µl (HR 2.3, 95% CI 1.19–4.44, p = 0.01) and body mass index (BMI) <18.5 (HR 2.15, 95% CI 1.07–4.3, p = 0.03). The pre-cART proportion of activated T-cells, as well as the immunologic and virologic response to ART were not associated with IRIS development. All patients continued on ART, 7 (19.4%) required hospitalization and there were 3 deaths (8.3%) attributable to IRIS. Conclusions IRIS is common in patients initiating ART in rural Mozambique. Pre-ART CD4 counts and BMI can easily be assessed at ART initiation in rural sub-Saharan Africa to identify patients at high risk of IRIS, for whom close supervision is warranted.
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Affiliation(s)
- Emilio Letang
- Centro de Investigação em Saúde de Manhiça (CISM), Manhiça, Maputo, Mozambique
- Barcelona Centre for International Health Research (CRESIB), Hospital Clínic/IDIBAPS, Universitat de Barcelona, Barcelona, Spain
- * E-mail: (EL); (DN)
| | - José M. Miró
- Infectious Diseases Service, Hospital Clínic/IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Tacilta Nhampossa
- Centro de Investigação em Saúde de Manhiça (CISM), Manhiça, Maputo, Mozambique
| | - Edgar Ayala
- Barcelona Centre for International Health Research (CRESIB), Hospital Clínic/IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Joaquim Gascon
- Barcelona Centre for International Health Research (CRESIB), Hospital Clínic/IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Clara Menéndez
- Centro de Investigação em Saúde de Manhiça (CISM), Manhiça, Maputo, Mozambique
- Barcelona Centre for International Health Research (CRESIB), Hospital Clínic/IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Pedro L. Alonso
- Centro de Investigação em Saúde de Manhiça (CISM), Manhiça, Maputo, Mozambique
- Barcelona Centre for International Health Research (CRESIB), Hospital Clínic/IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Denise Naniche
- Centro de Investigação em Saúde de Manhiça (CISM), Manhiça, Maputo, Mozambique
- Barcelona Centre for International Health Research (CRESIB), Hospital Clínic/IDIBAPS, Universitat de Barcelona, Barcelona, Spain
- * E-mail: (EL); (DN)
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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] [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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Cryptococcal immune reconstitution inflammatory syndrome in HIV-1-infected individuals: proposed clinical case definitions. THE LANCET. INFECTIOUS DISEASES 2010; 10:791-802. [PMID: 21029993 DOI: 10.1016/s1473-3099(10)70170-5] [Citation(s) in RCA: 226] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Cryptococcal immune reconstitution inflammatory syndrome (IRIS) may present as a clinical worsening or new presentation of cryptococcal disease after initiation of antiretroviral therapy (ART), and is thought to be caused by recovery of cryptococcus-specific immune responses. We have reviewed reports of cryptococcal IRIS and have developed a consensus case definition specifically for paradoxical crytopcoccal IRIS in patients with HIV-1 and known cryptococcal disease before ART, and a separate definition for incident cryptococcosis developed during ART (termed ART-associated cryptococcosis), for which a proportion of cases are likely to be unmasking cryptococcal IRIS. These structured case definitions are intended to aid design of future clinical, epidemiological, and immunopathological studies of cryptococcal IRIS, to standardise diagnostic criteria, and to facilitate comparisons between studies. As for definitions of tuberculosis-associated IRIS, definitions for cryptococcal IRIS should be regarded as preliminary until further insights into the immunopathology of IRIS permit their refinement.
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HIV protease inhibitors alter innate immune response signaling to double-stranded RNA in oral epithelial cells: implications for immune reconstitution inflammatory syndrome? AIDS 2010; 24:2587-90. [PMID: 20841991 DOI: 10.1097/qad.0b013e32833f4022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In this investigation, several HIV protease inhibitors altered the virally associated, double-stranded RNA (dsRNA)-stimulated, innate immune response. Lopinavir, the most potent inducer of interleukin (IL)-8 expression, also inhibited dsRNA-induced monocyte chemotactic protein 1 expression. Further analyses demonstrated that nuclear factor-κB is required for lopinavir's induction of IL-8. These findings demonstrate that protease inhibitors, such as lopinavir, differentially dysregulate innate immune signaling in a manner that could affect immune (reconstitution) inflammatory responses in oral epithelium.
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Superficial thrombophlebitis: A new clinical manifestation of the immune reconstitution inflammatory syndrome in a patient with HIV infection. Am J Dermatopathol 2010; 32:846-9. [PMID: 20881830 DOI: 10.1097/dad.0b013e3181d88d2e] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Skin manifestations of immune reconstitution inflammatory syndrome in response to highly active antiretroviral therapy may account for up to 50% of the clinical presentations in this syndrome. Viable or dying infective antigens, host antigens, tumoral antigens, and others may target immune reconstitution inflammatory syndrome, resulting in a wide spectrum of clinical manifestations. We describe a 26-year-old HIV-infected man who had started highly active antiretroviral therapy a few months earlier. He developed multiple linear nodules following the superficial veins in both legs. Histopathologic examination demonstrated a mostly septal panniculitis with features of superficial thrombophlebitis. We propose that superficial thrombophlebitis should be added to the list of clinical manifestations of this newly observed immune restoration disease.
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Immunopathogenesis of immune reconstitution disease in HIV patients responding to antiretroviral therapy. Curr Opin HIV AIDS 2009; 3:419-24. [PMID: 19373000 DOI: 10.1097/coh.0b013e328302ebbb] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The aim of this article is to review the most recent literature regarding the immunopathogenesis of pathogen-associated immune reconstitution disease and to discuss the role of immune activation and various effector molecules and cells such as macrophages, effector and regulatory T cells, and natural killer cells in immune reconstitution disease. RECENT FINDINGS Many HIV patients receiving antiretroviral treatment develop immune reconstitution disease, which is characterized by exaggerated inflammatory immune responses to replicating or dead pathogens. In the majority of these cases, immune reconstitution disease is associated with restoration of pathogen-specific cellular immune responses involving CD4 or CD8 effector T cells. The precise conditions that trigger immune reconstitution disease have not yet been identified. Immune reconstitution disease patients have overt immune activation, which may be due to poor homeostatic control after the fast initial immune recovery in patients receiving antiretroviral therapy. Poor homeostatic control in immune reconstitution disease patients may be linked to unbalanced restoration of effector and regulatory T cells. SUMMARY Although the precise mechanism of immune reconstitution disease is not well understood, it is probably related to rapid restoration of pathogen-specific immune responses and poor homeostatic control that promote exaggerated immunopathological responses, especially if viable pathogens or pathogen debris are present at high concentrations.
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Immune reconstitution disease: recent developments and implications for antiretroviral treatment in resource-limited settings. Curr Opin HIV AIDS 2009; 2:339-45. [PMID: 19372909 DOI: 10.1097/coh.0b013e3281a3c0a6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE OF REVIEW We review literature published over the past 2 years regarding the immunopathogenesis, epidemiology, clinical spectrum and outcomes of immune reconstitution disease in patients receiving antiretroviral treatment. Particular attention is drawn to data relevant to resource-limited settings. RECENT FINDINGS In high-income countries, immune reconstitution disease occurs in association with a largely predictable spectrum of pathogens, including the herpesviruses, Mycobacterium tuberculosis and Mycobacterium avium complex, Cryptococcus neoformans and hepatitis viruses. Dermatological manifestations are most frequent. In resource-limited settings, patients accessing antiretroviral treatment programmes typically have advanced immunodeficiency, which increases risk of immune reconstitution disease. M. tuberculosis and C. neoformans have emerged as the key causes of morbidity and mortality associated with immune reconstitution disease. An increasing number of 'tropical' infections, including leprosy, schistosomiasis, strongyloidiasis, leishmaniasis, histoplasmosis and many nontuberculous mycobacteria, are also now recognised to provoke immune reconstitution disease but the overall spectrum and relative importance of these organisms remain to be defined. Better characterisation of immune reconstitution disease in these settings is needed to enable development of guidelines regarding prevention, diagnosis and management. SUMMARY While immune reconstitution disease in high-income countries has been clinically and epidemiologically well described, much remains to be learned in resource-limited settings in which immune reconstitution disease is emerging as a significant cause of morbidity and mortality.
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Cryptococcal immune reconstitution inflammatory syndrome presenting with erosive bone lesions, arthritis and subcutaneous abscesses. AIDS 2009; 23:2371-3. [PMID: 19865031 DOI: 10.1097/qad.0b013e328330975f] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Weiss DA, Yang G, Myers JB, Breyer BN. Condyloma Overgrowth Caused by Immune Reconstitution Inflammatory Syndrome. Urology 2009; 74:1013-4. [DOI: 10.1016/j.urology.2009.04.076] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2009] [Revised: 04/19/2009] [Accepted: 04/29/2009] [Indexed: 11/15/2022]
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Osei-Sekyere B, Karstaedt AS. Immune reconstitution inflammatory syndrome involving the skin. Clin Exp Dermatol 2009; 35:477-81. [DOI: 10.1111/j.1365-2230.2009.03620.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Meys R, Gotch FM, Bunker CB. Human papillomavirus in the era of highly active antiretroviral therapy for human immunodeficiency virus: an immune reconstitution-associated disease? Br J Dermatol 2009; 162:6-11. [PMID: 19709102 DOI: 10.1111/j.1365-2133.2009.09365.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Human immunodeficiency virus (HIV)-related cutaneous and anogenital disease in the highly active antiretroviral therapy (HAART) era presents challenging problems for dermatologists. Immune reconstitution-associated diseases (IRADs) are common and important consequences of HAART. Dermatologists should be aware of the cutaneous manifestations of IRAD. The prevalence of clinical human papillomavirus (HPV)-related disease is increased in HIV and does not appear to be diminished by HAART. Many patients on HAART are dogged by persistent cutaneous warts. Anogenital precancer is also common in HIV and may be burgeoning with HAART. Clinicians should be aware of the increased risk of cervical, penile and vulval/vaginal cancers in treated and untreated patients with HIV. The increase in HPV infection in HIV-infected individuals may be, at least partly, due to increased exposure to diverse HPV types, particularly high-risk types that might be able to persist for longer in anogenital regions. Alternatively, persistent/emergent HPV disease in HIV infection might represent persistent or modulated immunodysregulation after HAART and be viewed as a form of IRAD. The immunopathogenesis of HPV IRAD is fascinating and possibly determined by host genotype.
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Affiliation(s)
- R Meys
- Department of Dermatology, Chelsea and Westminster Hospital, Imperial College, 369 Fulham Rd, London SW10 9NH, UK
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