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Wang Y, Yang J, Wen Y. The Peculiarity of Infection and Immunity Correlated with Guillain-Barré Syndrome in the HIV-Infected Population. J Clin Med 2023; 12:jcm12030907. [PMID: 36769555 PMCID: PMC9917483 DOI: 10.3390/jcm12030907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/05/2023] [Accepted: 01/16/2023] [Indexed: 01/26/2023] Open
Abstract
Guillain-Barré syndrome (GBS) can occur at all stages of human immunodeficiency virus (HIV) infection. HIV, cytomegalovirus (CMV), and varicella zoster virus (VZV) are the main infectious agents in HIV-positive GBS cases. These cases include acute and chronic HIV infection, immune reconstitution inflammatory syndrome (IRIS) shortly after anti-retroviral therapy (ART), those with ART interruption, or those with cerebrospinal fluids (CSF) HIV escape. The mechanisms are involved in both humoral and cellular immunities. Demyelinating and axonal neuropathies are the main pathological mechanisms in GBS. Presentation and prognosis are identical to those in patients without HIV infection. Typical or atypical clinical manifestations, CSF analysis, electrophysiological and pathological examination, and antiganglioside antibody detection can help diagnose GBS and classify its various subtypes. Intravenous immunoglobulin and plasma exchange have been used to treat GBS in HIV-positive patients with a necessary ART, while ganciclovir or foscarnet sodium should be used to treat ongoing CMV- or VZV-associated GBS. Steroids may be beneficial for patients with IRIS-related GBS. We reviewed HIV-positive cases with GBS published since 2000 and summarized their features to highlight the necessity of HIV testing among patients with GBS. Moreover, the establishment of a multidisciplinary team will guarantee diagnostic and therapeutic advantages.
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Affiliation(s)
- Yanli Wang
- Department of Infectious Diseases, The First Affiliated Hospital of China Medical University, Shenyang 110001, China
| | - Jun Yang
- Neurology Department, The First Affiliated Hospital of China Medical University, Shenyang 110001, China
| | - Ying Wen
- Department of Infectious Diseases, The First Affiliated Hospital of China Medical University, Shenyang 110001, China
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2
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Wang J, Zhang Y, Wang M, Ren Y, Tang M, Liu L, Zhou D. Intravenous immunoglobulin therapy for HIV-associated Guillain-Barré syndrome. Int Immunopharmacol 2022; 112:109192. [PMID: 36155283 DOI: 10.1016/j.intimp.2022.109192] [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: 05/26/2022] [Revised: 08/19/2022] [Accepted: 08/20/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To compare the efficacy of intravenous immunoglobulin (IVIG) added to antiretroviral therapy (ART) and ART alone in people living with human immunodeficiency virus-associated Guillain-Barré syndrome (HIV-associated GBS). METHODS The study was a retrospective analysis of clinical records of HIV-associated GBS patients from department of neurology at West China Hospital between January 2015 and October 2020. Patients treated with ART alone were compared with those treated with IVIG + ART. The primary outcome was the GBS disability score at 4 weeks, which was assessed with multivariable ordinal regression. Additional outcomes include the GBS disability scale at 1 week, improvement of ≥ 1 point on the GBS disability score at 1 and 4 weeks, median change in the MRC sum score at 1 and 4 weeks, number of patients who were able to walk independently at 4 weeks. RESULTS Two hundred and fifty-two (252) individuals living with HIV were recruited in the study. According to the inclusion and exclusion criteria, 21 HIV-associated GBS patients were finally included, of whom 8 were treated with IVIG + ART and 13 were treated with ART alone. At the fourth weeks after treatment, the GBS disability scale grade was significantly lower in patients treated with IVIG + ART than those with ART alone (1 vs. 2, P = 0.02). The adjusted OR for a lower GBS disability scale was 10.6 (95 % CI 1.15 to 98.05; P = 0.03) for the IVIG + ART group. Moreover, 6 of 8 (75 %) patients treated with IVIG + ART were able to walk independently at four weeks after treatment. CONCLUSIONS The introduction of IVIG combined with ART may be efficacious in the treatment of HIV-infected GBS and may provide better clinical outcomes.
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Affiliation(s)
- Jierui Wang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yu Zhang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Department of Neurology, Cheng Du Shang Jin Nan Fu Hospital, Chengdu, Sichuan, China
| | - Minjin Wang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yan Ren
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Meng Tang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ling Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
| | - Dong Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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Vidal JE, Guedes BF, Gomes HR, Mendonça RH. Guillain-Barré syndrome spectrum as manifestation of HIV-related immune reconstitution inflammatory syndrome: case report and literature review. Braz J Infect Dis 2022; 26:102368. [PMID: 35605654 PMCID: PMC9387489 DOI: 10.1016/j.bjid.2022.102368] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 04/30/2022] [Indexed: 11/29/2022] Open
Abstract
A 34-year-old man presented with a history of 21-days of gait unsteadiness and diplopia. Ten days before presentation, he developed limb weakness and in the last three days reduced consciousness. HIV infection was diagnosed three months ago (CD4+ = 160 cells/mm3; viral load HIV-1 = 144.000 copies/mL), and antiretroviral therapy was initiated. Impaired consciousness, ophthalmoplegia, limb weakness, ataxia, areflexia, and Babinsky´s sign were noted. At that moment, CD4+ count was 372 cells/mm 3 and viral load HIV-1 <50 copies/mL. The clinical, laboratory and neurophysiological findings suggest overlapping Guillain-Barre syndrome (GBS) and Bickerstaff brainstem encephalitis as manifestation of HIV-related immune reconstitution inflammatory syndrome (IRIS). Here, we review and discuss 7 cases (including the present report) of GBS spectrum as manifestation of HIV-related IRIS.
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Affiliation(s)
- José E Vidal
- Instituto de Infectologia Emilio Ribas, São Paulo, SP, Brazil; Hospital das Clınicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil; Instituto de Medicina Tropical da Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Bruno F Guedes
- Hospital das Clınicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Hélio R Gomes
- Hospital das Clınicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Rodrigo Holanda Mendonça
- Hospital das Clınicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
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4
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Ndondo AP, Eley B, Wilmshurst JM, Kakooza-Mwesige A, Giannoccaro MP, Willison HJ, Cruz PMR, Heckmann JM, Bateman K, Vincent A. Post-Infectious Autoimmunity in the Central (CNS) and Peripheral (PNS) Nervous Systems: An African Perspective. Front Immunol 2022; 13:833548. [PMID: 35356001 PMCID: PMC8959857 DOI: 10.3389/fimmu.2022.833548] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 02/10/2022] [Indexed: 11/13/2022] Open
Abstract
The direct impact and sequelae of infections in children and adults result in significant morbidity and mortality especially when they involve the central (CNS) or peripheral nervous system (PNS). The historical understanding of the pathophysiology has been mostly focused on the direct impact of the various pathogens through neural tissue invasion. However, with the better understanding of neuroimmunology, there is a rapidly growing realization of the contribution of the innate and adaptive host immune responses in the pathogenesis of many CNS and PNS diseases. The balance between the protective and pathologic sequelae of immunity is fragile and can easily be tipped towards harm for the host. The matter of immune privilege and surveillance of the CNS/PNS compartments and the role of the blood-brain barrier (BBB) and blood nerve barrier (BNB) makes this even more complex. Our understanding of the pathogenesis of many post-infectious manifestations of various microbial agents remains elusive, especially in the diverse African setting. Our exploration and better understanding of the neuroimmunology of some of the infectious diseases that we encounter in the continent will go a long way into helping us to improve their management and therefore lessen the burden. Africa is diverse and uniquely poised because of the mix of the classic, well described, autoimmune disease entities and the specifically "tropical" conditions. This review explores the current understanding of some of the para- and post-infectious autoimmune manifestations of CNS and PNS diseases in the African context. We highlight the clinical presentations, diagnosis and treatment of these neurological disorders and underscore the knowledge gaps and perspectives for future research using disease models of conditions that we see in the continent, some of which are not uniquely African and, where relevant, include discussion of the proposed mechanisms underlying pathogen-induced autoimmunity. This review covers the following conditions as models and highlight those in which a relationship with COVID-19 infection has been reported: a) Acute Necrotizing Encephalopathy; b) Measles-associated encephalopathies; c) Human Immunodeficiency Virus (HIV) neuroimmune disorders, and particularly the difficulties associated with classical post-infectious autoimmune disorders such as the Guillain-Barré syndrome in the context of HIV and other infections. Finally, we describe NMDA-R encephalitis, which can be post-HSV encephalitis, summarise other antibody-mediated CNS diseases and describe myasthenia gravis as the classic antibody-mediated disease but with special features in Africa.
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Affiliation(s)
- Alvin Pumelele Ndondo
- Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Brian Eley
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa.,Paediatric Infectious Diseases Unit, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Jo Madeleine Wilmshurst
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa.,Department of Paediatric Neurology, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Angelina Kakooza-Mwesige
- Department of Pediatrics and Child Health, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Maria Pia Giannoccaro
- Laboratory of Neuromuscular Pathology and Neuroimmunology, Istituto di Ricovero e Cura a CarattereScientifico (IRCCS) Instiuto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica Bologna, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Hugh J Willison
- Institute of Infection, Immunity and Inflammation (3I), University of Glasgow, Glasgow, United Kingdom
| | - Pedro M Rodríguez Cruz
- Centro Nacional de Analisis Genomico - Centre for Genomic Regulation (CNAG-CRG ), Centre for Genomic Regulation (CRG), The Barcelona Institute of Science and Technology, Barcelona, Spain.,Department of Neuromuscular Disease, University College London (UCL) Queen Square Institute of Neurology, London, United Kingdom.,Faculté de Médecine, de Pharmacie et d'Odontologie, Université Cheikh Anta Diop, Dakar, Senegal
| | - Jeannine M Heckmann
- Neurology Division, Department of Medicine, Groote Schuur Hospital, Cape Town, South Africa.,The University of Cape Town (UCT) Neurosciences Institute, University of Cape Town, Cape Town, South Africa
| | - Kathleen Bateman
- Neurology Division, Department of Medicine, Groote Schuur Hospital, Cape Town, South Africa
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
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Cheng AC, Lin TY, Wang NC. Immune Reconstitution Inflammatory Syndrome Induced by Mycobacterium avium Complex Infection Presenting as Chronic Inflammatory Demyelinating Polyneuropathy in a Young AIDS Patient. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58010110. [PMID: 35056418 PMCID: PMC8779113 DOI: 10.3390/medicina58010110] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 01/05/2022] [Accepted: 01/05/2022] [Indexed: 12/26/2022]
Abstract
Antiretroviral therapy (ART) can restore protective immune responses against opportunistic infections (OIs) and reduce mortality in patients with human immunodeficiency virus (HIV) infections. Some patients treated with ART may develop immune reconstitution inflammatory syndrome (IRIS). Mycobacterium avium complex (MAC)-related IRIS most commonly presents as lymphadenitis, soft-tissue abscesses, and deteriorating lung infiltrates. However, neurological presentations of IRIS induced by MAC have been rarely described. We report the case of a 31-year-old man with an HIV infection. He developed productive cough and chronic inflammatory demyelinating polyneuropathy (CIDP) three months after the initiation of ART. He experienced an excellent virological and immunological response. Sputum culture grew MAC. The patient was diagnosed with MAC-related IRIS presenting as CIDP, based on his history and laboratory, radiologic, and electrophysiological findings. Results: Neurological symptoms improved after plasmapheresis and intravenous immunoglobulin (IVIG) treatment. To our knowledge, this is the first reported case of CIDP due to MAC-related IRIS. Clinicians should consider MAC-related IRIS in the differential diagnosis of CIDP in patients with HIV infections following the initiation of ART.
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Affiliation(s)
- An-Che Cheng
- Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei City 11490, Taiwan;
| | - Te-Yu Lin
- Division of Infectious Disease and Tropical Medicine, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei City 11490, Taiwan;
| | - Ning-Chi Wang
- Division of Infectious Disease and Tropical Medicine, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei City 11490, Taiwan;
- Correspondence: ; Tel.: +886-2-287927257
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Luciano CA, Caraballo-Cartagena S. Treatment and Management of Infectious, Granulomatous, and Toxic Neuromuscular Disorders. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00016-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
PURPOSE OF REVIEW This article reviews the neurologic complications associated with human immunodeficiency virus (HIV) infection. RECENT FINDINGS Neurologic complications of HIV may be caused by direct virally mediated pathology, immune-mediated phenomena in response to viral infection, or opportunistic infections secondary to depletion of lymphocytes. These neurologic disorders may be influenced by the degree of immunosuppression (ie, CD4+ T-cell lymphocyte count) and stage of infection (early versus late), as well as use of antiretroviral therapy, and may manifest as a variety of central and peripheral neurologic syndromes, including the more commonly encountered HIV-associated cognitive disorders and length-dependent sensorimotor polyneuropathy, respectively. Immune dysregulation underlies the majority of these neurologic phenomena, as well as other HIV-associated conditions including immune reconstitution inflammatory syndrome (IRIS), CD8 lymphocytosis, and potentially the development of compartmentalized infection within the CSF, also referred to as CSF escape. SUMMARY This article reviews a spectrum of clinical syndromes and related neuropathologic states associated with HIV infection.
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8
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Review of the neurological aspects of HIV infection. J Neurol Sci 2021; 425:117453. [PMID: 33895464 DOI: 10.1016/j.jns.2021.117453] [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: 08/12/2020] [Revised: 04/12/2021] [Accepted: 04/12/2021] [Indexed: 11/20/2022]
Abstract
There are almost 40 million people in the world who live with the human immunodeficiency virus (HIV). The neurological manifestations associated with HIV contribute to significant morbidity and mortality despite the advances made with anti-retroviral therapy (ART). This review presents an approach to classification of neurological disorders in HIV, differentiating diseases due to the virus itself and those due to opportunistic infection. The effects of antiretroviral therapy are also discussed. The emphasis is on the developing world where advanced complications of HIV itself and infections such as tuberculosis (TB), toxoplasmosis and cryptococcal meningitis remain prevalent.
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9
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Mulroy E, Anderson NE. Altered mental status in "Guillain-Barré syndrome" -a noteworthy clinical clue. Ann Clin Transl Neurol 2020; 7:2489-2507. [PMID: 33136342 PMCID: PMC7732251 DOI: 10.1002/acn3.51226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 09/19/2020] [Accepted: 09/26/2020] [Indexed: 01/01/2023] Open
Abstract
Guillain-Barré syndrome (GBS) is widely regarded as a "pure" peripheral nervous system disorder. However, this simplistic interpretation belies the fact that central nervous system involvement, often manifesting as derangements in mental status can occur as a complication of the "pure" form of the disorder, as part of GBS variants, as well as in a number of mimic disorders. Despite being common in clinical practice, there is no guidance in the literature as to how to approach such scenarios. Herein, we detail our approach to these cases.
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Affiliation(s)
- Eoin Mulroy
- UCL Queen Square Institute of NeurologyLondonUK
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10
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Abstract
PURPOSE OF REVIEW To summarize the recent data regarding Guillain-Barré syndrome (GBS) as an autoimmune disorder following infection with Zika virus (ZIKV) infection, including the proposed pathogenic mechanisms and the role of autoantibodies. RECENT FINDINGS The loss of self-tolerance that leads to autoimmune diseases is a multifactorial process that may be illustrated as 'the mosaic of autoimmunity'. Infectious agents may contribute to the development of autoimmunity by several proposed mechanisms. One of the central mechanisms is molecular mimicry, which is also the most plausible mechanism in the case of ZIKV-induced autoimmune disorders.A recent meta-analysis found a low prevalence of GBS associated with ZIKV infection. Nevertheless, the estimated cost of illness for patients with GBS associated with ZIKV are tremendous and exceed 4.7 million dollars per year in Brazil alone. SUMMARY Currently, there is sufficient data to indicate that ZIKV infection is one of many triggers and factors that may contribute to the development GBS. Thus, it is advised to evaluate and determine ZIKV exposure and infection in the management of potential GBS patients.
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Joseph J, Nathenson MJ, Trinh VA, Malik K, Nowell E, Carter K, Weathers SP, Demetri GD, Araujo D, Conley AP. Guillain-Barre syndrome observed with adoptive transfer of lymphocytes genetically engineered with an NY-ESO-1 reactive T-cell receptor. J Immunother Cancer 2019; 7:296. [PMID: 31703609 PMCID: PMC6842215 DOI: 10.1186/s40425-019-0759-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 09/26/2019] [Indexed: 02/07/2023] Open
Abstract
Background Adoptive transfer of autologous T-lymphocytes transduced with a high affinity NY-ESO-1-reactive T-cell receptor (NY-ESO-1c259 T-cells) has emerged as a promising therapeutic strategy for patients with refractory synovial sarcoma. Secondary autoimmune T-cell mediated toxicities can occur long after initial adoptive T-cell transfer. We report on the first two cases of the development and management of Guillain-Barre syndrome in synovial sarcoma patients who received NY-ESO-1c259 T-cells. Case presentation A 47 year-old woman and 39 year-old woman with refractory metastatic SS were treated with fludarabine-cyclophosphamide lymphodepletion followed by adoptive transfer of NY-ESO-1c259 T-cells. On day 42 after adoptive T-cell therapy, patient one presented to the emergency room with a one-week history of numbness, paresthesia, and heaviness to both legs progressing to difficulty walking on the day of presentation. Although MRI brain and lumbar puncture were negative, electromyography (EMG) and nerve conduction studies (NCS) of the lower extremities and right arm performed revealed an abnormal study suggestive of a very mild, distal, motor, axonal polyneuropathy. Patient two presented on day 113 with bilateral foot numbness, left foot drop, unsteady gait, and pain in the left thigh, which progressed over two week to bilateral leg weakness, inability to walk, and numbness bilaterally in the hands, legs, and feet. Both patients received intravenous immunoglobulin (IVIG) 0.4 g/kg/day for 5 days for possible acute inflammatory demyelinating polyneuropathy (AIDP) likely related to NY-ESO-1 targeting T-cell therapy. After 3 and 5 doses, respectively, of IVIG, the patients reported improvement in symptoms and strength, and were later transferred to an inpatient rehabilitation facility to continue gaining strength. At patient one’s neurology follow-up on day 95, she reported only mild left lower extremity (LLE) weakness and was gradually successfully regaining independence in motor function. At patient two’s 9-month follow-up, the patient had regained normal function and independence. Conclusions Given the expanding applications of immunotherapy in cancer management, clinicians should stay vigilant against the potential development of unusual but life-threatening immune-mediated toxicities.
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Affiliation(s)
- Jocelyn Joseph
- Department of Clinical Pharmacy Services, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, USA.
| | - Michael J Nathenson
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Brighton, MA, USA
| | - Van Anh Trinh
- Department of Clinical Pharmacy Services, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, USA
| | - Karan Malik
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Brighton, MA, USA
| | - Erica Nowell
- Department of Sarcoma Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, USA
| | - Kristen Carter
- Department of Sarcoma Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, USA
| | - Shiao-Pei Weathers
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, USA
| | - George D Demetri
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Brighton, MA, USA
| | - Dejka Araujo
- Department of Sarcoma Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, USA
| | - Anthony P Conley
- Department of Sarcoma Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, USA
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Sathirapanya P, Fujitnirun C, Setthawatcharawanich S, Phabphal K, Limapichat K, Chayakul P, Silpapojakul K, Jaruratanasirikul S, Siripaitoon P, Chusri S, Kositpantawong N. Peripheral facial paralysis associated with HIV infection: A case series and literature review. Clin Neurol Neurosurg 2018; 172:124-129. [PMID: 29990960 DOI: 10.1016/j.clineuro.2018.06.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 06/23/2018] [Accepted: 06/30/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The association between peripheral facial paralysis (PFP) and HIV infection has been scarcely explained. The authors aimed to describe the association between PFP and HIV infection status, along with the related co-morbidities and the outcomes of PFP, as well as the literature review on this topic. PATIENTS AND METHODS All HIV-infected patients who experienced PFP, both before and after a positive HIV serology test, between January 2002 and June 2015 were retrospectively reviewed. The patients' demographic data, clinical characteristics, HIV co-morbidities and outcomes of PFP were summarized. A literature review of PFP in HIV infection was also performed. Descriptive statistics were used in the data analysis. The Mann-Whitney U test was performed to compare the parameters between the current case series and cases from literature review to determine statistical significant differences (p < 0.05). RESULTS Sixteen patients (6 males and 10 females) were enrolled. Their median age was significantly higher than that of the cases in the literature review [46 (38, 49.75) vs. 33 (26, 41) years (p = 0.004)]. Nonetheless, a non-significant lower median CD4 count was observed [274 (134.5, 425.5) vs. 373 (265, 718) cells/μL (p = 0.058)]. In our series, unilateral PFP (UFP) was the most frequent, and it typically occurred long after a positive HIV serology test. However, bilateral PFP (BFP) was commonly found in the literature, and a simultaneous positive HIV serology test was reported in almost all cases. Consequently, most of our cases, except for those with HIV-related complications or co-morbidities, experienced a satisfactory recovery from PFP regardless of treatments received. CONCLUSIONS Most of the cases in our series were UPF with a higher median age and a lower median CD4 count. Moreover, facial paralysis presented later in our series than in the previously reported cases in the literature. Most of our cases experienced satisfactory recovery of facial weakness.
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Affiliation(s)
- Pornchai Sathirapanya
- Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110 Thailand.
| | - Chris Fujitnirun
- Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110 Thailand
| | | | - Kanitpong Phabphal
- Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110 Thailand
| | - Kitti Limapichat
- Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110 Thailand
| | - Pantip Chayakul
- Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110 Thailand
| | - Khachornsakdi Silpapojakul
- Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110 Thailand
| | - Sutep Jaruratanasirikul
- Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110 Thailand
| | - Pisud Siripaitoon
- Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110 Thailand
| | - Sarunyou Chusri
- Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110 Thailand
| | - Narongdet Kositpantawong
- Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110 Thailand
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13
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Mathukumalli NL, Ali N, Kanikannan MA, Yareeda S. Worsening Guillain-Barré syndrome: harbinger of IRIS in HIV? BMJ Case Rep 2017; 2017:bcr-2017-221874. [PMID: 29030378 DOI: 10.1136/bcr-2017-221874] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report an HIV patient aged 38 years with acute inflammatory demyelinating polyradiculoneuropathy subtype of Guillain-Barré syndrome (GBS) as the only manifestation of seroconversion and worsening of GBS being the harbinger of immune reconstitution inflammatory syndrome (IRIS). To date, only 5 cases of GBS during IRIS are reported. They manifested either during the third week or later after starting highly active antiretroviral therapy (HAART). Our patient witnessed worsening weakness by fifth day after starting HAART, even before the occurrence of Pneumocystis jirovecii pneumonia, cautioning one of the impending serious complications of IRIS and helped us initiate steroids at an early date.
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Affiliation(s)
| | - Niloufer Ali
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Meena A Kanikannan
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Sireesha Yareeda
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
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14
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Liu P, Dillingham R, McManus KA. Hospital days attributable to immune reconstitution inflammatory syndrome in persons living with HIV before and after the 2012 DHHS HIV guidelines. AIDS Res Ther 2017; 14:25. [PMID: 28469696 PMCID: PMC5414162 DOI: 10.1186/s12981-017-0152-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 04/26/2017] [Indexed: 12/24/2022] Open
Abstract
Background Immune reconstitution inflammatory syndrome (IRIS) can manifest with initiation or reintroduction of antiretroviral therapy (ART) in persons living with HIV (PLWH). In 2012, updated United States treatment guidelines recommended initiation of ART for all PLWH regardless of CD4 count. The objectives of this study were to quantify hospital usage attributable to IRIS and assess the reasons for hospitalization in PLWH before and after the guideline update. Methods Subjects were PLWH between 18–89 years of age who were hospitalized between November 1, 2009 and July 31, 2014. Equivalent time periods before and after updated treatment guidelines were considered, and designated as Time Period 1 and Time Period 2, respectively. IRIS-attributable hospitalizations were identified by ICD9 codes and electronic medical record searches with subsequent review and confirmation. For hospitalizations that were not confirmed as being IRIS-attributable, primary discharge diagnoses were reviewed. Results A total of 278 PLWH were hospitalized 521 times throughout the study period. Time Period 1 had 9 PLWH with 12 IRIS-attributable hospitalizations while Time Period 2 had 6 PLWH with 9 IRIS-attributable hospitalizations. A larger proportion of IRIS-attributable hospital days was observed in Time Period 1 compared to Time Period 2 (7.5 vs 4.2%; p < 0.001). Median length of stay for IRIS-attributable hospitalizations was longer than for other diagnoses, particularly during Time Period 1 (12.0 vs 4.0; p = 0.05). The most common causes for hospitalizations in PLWH were non AIDS-defining infection, AIDS-defining malignancy, and gastrointestinal. PLWH who had HIV viral suppression (<200 copies/mL) accounted for 34 and 24% of hospitalizations in Time Periods 1 and 2 respectively. Conclusions Hospitalizations for PLWH continue at high rates and IRIS is a significant contributing factor. In our single-center study, there was a lower number of IRIS-attributable hospitalizations and IRIS-attributable hospital days in Time Period 2 compared with Time Period 1. The hospital burden of IRIS may decrease over time as more PLWH are started on ART earlier in the course of infection. This study highlights the continued importance of early diagnosis and linkage to care of those infected with HIV, so that morbidity and costs associated with IRIS continue to decline.
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Pinto-Díaz CA, Rodríguez Y, Monsalve DM, Acosta-Ampudia Y, Molano-González N, Anaya JM, Ramírez-Santana C. Autoimmunity in Guillain-Barré syndrome associated with Zika virus infection and beyond. Autoimmun Rev 2017; 16:327-334. [PMID: 28216074 DOI: 10.1016/j.autrev.2017.02.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 12/05/2016] [Indexed: 12/15/2022]
Abstract
Autoimmune diseases share common immunopathogenic mechanisms (i.e., the autoimmune tautology), which explain the clinical similarities among them as well as their familial clustering. Guillain-Barré syndrome (GBS), an autoimmune peripheral neuropathy, has been recently associated with Zika virus (ZIKV) infection. Based on a series of cases, this review article provides a comparative analysis of GBS associated with ZIKV infection, contrasted with the general characteristics of GBS in light of the autoimmune tautology, including gender differences in prevalence, subphenotypes, polyautoimmunity, familial autoimmunity, age at onset, pathophysiology, ecology, genetics, ancestry, and treatment.
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Affiliation(s)
- Carlos A Pinto-Díaz
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Carrera 24 No. 63-C-69, Bogotá, Colombia
| | - Yhojan Rodríguez
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Carrera 24 No. 63-C-69, Bogotá, Colombia
| | - Diana M Monsalve
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Carrera 24 No. 63-C-69, Bogotá, Colombia
| | - Yeny Acosta-Ampudia
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Carrera 24 No. 63-C-69, Bogotá, Colombia
| | - Nicolás Molano-González
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Carrera 24 No. 63-C-69, Bogotá, Colombia
| | - Juan-Manuel Anaya
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Carrera 24 No. 63-C-69, Bogotá, Colombia
| | - Carolina Ramírez-Santana
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Carrera 24 No. 63-C-69, Bogotá, Colombia.
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Virot E, Duclos A, Adelaide L, Miailhes P, Hot A, Ferry T, Seve P. Autoimmune diseases and HIV infection: A cross-sectional study. Medicine (Baltimore) 2017; 96:e5769. [PMID: 28121924 PMCID: PMC5287948 DOI: 10.1097/md.0000000000005769] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
To describe the clinical manifestations, treatments, prognosis, and prevalence of autoimmune diseases (ADs) in human immunodeficiency virus (HIV)-infected patients.All HIV-infected patients managed in the Infectious Diseases Department of the Lyon University Hospitals, France, between January 2003 and December 2013 and presenting an AD were retrospectively included.Thirty-six ADs were found among 5186 HIV-infected patients which represents a prevalence of 0.69% including immune thrombocytopenic purpura (n = 15), inflammatory myositis (IM) (n = 4), sarcoidosis (n = 4), Guillain-Barré syndrome (GBS) (n = 4), myasthenia gravis (n = 2), Graves' disease (n = 2), and 1 case of each following conditions: systemic lupus erythematosus, rheumatoid arthritis, autoimmune hepatitis, Hashimoto thyroiditis and autoimmune hemolytic anemia. One patient presented 2 ADs. Thirty patients were known to be HIV-infected when they developed an AD. The AD preceded HIV infection in 2 patients. GBS and HIV infection were diagnosed simultaneously in 3 cases. At AD diagnosis, CD4 T lymphocytes count were higher than 350/mm in 63% of patients, between 200 and 350/mm in 19% and less than 200/mm in 19%. Twenty patients benefited from immunosuppressant treatments, with a good tolerance.ADs during HIV infection are uncommon in this large French cohort. Immune thrombocytopenic purpura, sarcoidosis, IM, and GBS appear to be more frequent than in the general population. Immunosuppressant treatments seem to be effective and well tolerated.
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Affiliation(s)
- Emilie Virot
- Département de Médecine Interne, Hôpital de la Croix-Rousse, Hospices Civils de Lyon
| | - Antoine Duclos
- Pôle Information Médicale Evaluation Recherche des Hospices Civils de Lyon
| | - Leopold Adelaide
- Département de Maladies Infectieuses, Hôpital de la Croix-Rousse, Hospices Civils de Lyon
| | - Patrick Miailhes
- Département de Maladies Infectieuses, Hôpital de la Croix-Rousse, Hospices Civils de Lyon
| | - Arnaud Hot
- Université de Lyon, Université Lyon 1
- Département de Médecine Interne, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Tristan Ferry
- Département de Maladies Infectieuses, Hôpital de la Croix-Rousse, Hospices Civils de Lyon
- Université de Lyon, Université Lyon 1
| | - Pascal Seve
- Département de Médecine Interne, Hôpital de la Croix-Rousse, Hospices Civils de Lyon
- Université de Lyon, Université Lyon 1
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Jasti AK, Selmi C, Sarmiento-Monroy JC, Vega DA, Anaya JM, Gershwin ME. Guillain-Barré syndrome: causes, immunopathogenic mechanisms and treatment. Expert Rev Clin Immunol 2016. [DOI: 10.1080/1744666x.2016.1193006 10.1080/1744666x.2016.1193006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Jasti AK, Selmi C, Sarmiento-Monroy JC, Vega DA, Anaya JM, Gershwin ME. Guillain-Barré syndrome: causes, immunopathogenic mechanisms and treatment. Expert Rev Clin Immunol 2016; 12:1175-1189. [PMID: 27292311 DOI: 10.1080/1744666x.2016.1193006] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Guillain-Barré syndrome is a rare disease representing the most frequent cause of acute flaccid symmetrical weakness of the limbs and areflexia usually reaching its peak within a month. The etiology and pathogenesis remain largely enigmatic and the syndrome results in death or severe disability in 9-17% of cases despite immunotherapy. Areas covered: In terms of etiology, Guillain-Barré syndrome is linked to Campylobacter infection but less than 0.1% of infections result in the syndrome. In terms of pathogenesis, activated macrophages and T cells and serum antibodies against gangliosides are observed but their significance is unclear. Expert commentary: Guillain-Barré syndrome is a heterogeneous condition with numerous subtypes and recent data point towards the role of ganglioside epitopes by immunohistochemical methods. Ultimately, the syndrome results from a permissive genetic background on which environmental factors, including infections, vaccination and the influence of aging, lead to disease.
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Affiliation(s)
- Anil K Jasti
- a Division of Rheumatology, Allergy, and Clinical Immunology , University of California Davis , Davis , CA , USA
| | - Carlo Selmi
- b Rheumatology and Clinical Immunology , Humanitas Research Hospital , Rozzano , Milan , Italy.,c BIOMETRA Department , University of Milan , Milan , Italy
| | - Juan C Sarmiento-Monroy
- d Center for Autoimmune Diseases Research (CREA) , Universidad del Rosario , Bogota , Colombia
| | - Daniel A Vega
- e Intensive Care Unit, Mederi, Hospital Universitario Mayor , Universidad del Rosario , Bogotá , Colombia
| | - Juan-Manuel Anaya
- d Center for Autoimmune Diseases Research (CREA) , Universidad del Rosario , Bogota , Colombia
| | - M Eric Gershwin
- a Division of Rheumatology, Allergy, and Clinical Immunology , University of California Davis , Davis , CA , USA
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Immune reconstitution disorders in patients with HIV infection: from pathogenesis to prevention and treatment. Curr HIV/AIDS Rep 2015; 11:223-32. [PMID: 24950732 DOI: 10.1007/s11904-014-0213-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
An immune reconstitution disorder occurs in up to 40 % of severely immunodeficient HIV patients who commence antiretroviral therapy (ART), with an immune reconstitution inflammatory syndrome (IRIS) being encountered most commonly. Differences in the immunopathogenesis of an IRIS associated with different types of pathogen have become apparent but common features have also been defined. These include severe immunodeficiency prior to commencing ART associated with a high pathogen load and 'compensatory' immune responses, particularly innate immune responses, which inadequately control the pathogen and increase the risk of immunopathology as the immune system recovers on ART. Prevention of an IRIS may be achieved by optimising therapy for opportunistic infections before ART is commenced, delaying ART or using immunomodulatory therapy to prevent or suppress the immune response that causes the immunopathology. However, further clinical studies are required to examine these options in a systematic manner for the various types of IRIS.
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20
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Afzal A, Benjamin M, Gummelt KL, Afzal S, Shamim S, Tribble M. Ascending paralysis associated with HIV infection. Proc AMIA Symp 2015; 28:25-8. [PMID: 25552790 PMCID: PMC4264702 DOI: 10.1080/08998280.2015.11929176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
We present two patients with a high viral load of HIV-1 who developed symptoms of ascending paralysis leading to respiratory failure and autonomic instability. One patient had symptom improvement with highly active antiretroviral therapy (HAART) and a subsequent decrease in viral load. The other patient improved with intravenous immunoglobulin therapy and did not show much improvement on HAART alone. There are several proposed mechanisms for peripheral neuropathies seen in HIV-infected patients, including a direct action of HIV on the nerve by neurotropic strains or formation of autoantibodies against nerve elements. The comparison of the response to different therapies in these two cases highlights the importance of understanding different pathophysiologies, as the treatment modality may differ.
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Affiliation(s)
- Aasim Afzal
- Department of Internal Medicine (Afzal, Benjamin, Gummelt), the Division of Neurology (Shamim), and the Division of Infectious Diseases (Tribble), Baylor University Medical Center at Dallas
| | - Mina Benjamin
- Department of Internal Medicine (Afzal, Benjamin, Gummelt), the Division of Neurology (Shamim), and the Division of Infectious Diseases (Tribble), Baylor University Medical Center at Dallas
| | - Kyle L Gummelt
- Department of Internal Medicine (Afzal, Benjamin, Gummelt), the Division of Neurology (Shamim), and the Division of Infectious Diseases (Tribble), Baylor University Medical Center at Dallas
| | - Sadaf Afzal
- Department of Internal Medicine (Afzal, Benjamin, Gummelt), the Division of Neurology (Shamim), and the Division of Infectious Diseases (Tribble), Baylor University Medical Center at Dallas
| | - Sadat Shamim
- Department of Internal Medicine (Afzal, Benjamin, Gummelt), the Division of Neurology (Shamim), and the Division of Infectious Diseases (Tribble), Baylor University Medical Center at Dallas
| | - Marc Tribble
- Department of Internal Medicine (Afzal, Benjamin, Gummelt), the Division of Neurology (Shamim), and the Division of Infectious Diseases (Tribble), Baylor University Medical Center at Dallas
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21
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Wakerley BR, Yuki N. Infectious and noninfectious triggers in Guillain-Barré syndrome. Expert Rev Clin Immunol 2014; 9:627-39. [PMID: 23899233 DOI: 10.1586/1744666x.2013.811119] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Guillain-Barré syndrome (GBS) is the commonest cause of acquired flaccid paralysis in the world and regarded by many as the prototype for postinfectious autoimmunity. Here the authors consider both infectious and noninfectious triggers of GBS and determine where possible what immunological mechanisms may account for this association. In approximately two-thirds of cases, an infectious trigger is reported in the weeks that lead up to disease onset, indicating that the host's response to infection must play an important role in disease pathogenesis. The most frequently identified bacteria, Campylobacter jejuni, through a process known as molecular mimicry, has been shown to induce cross-reactive anti-ganglioside antibodies, which can lead to the development of axonal-type GBS in some patients. Whether this paradigm can be extended to other infectious organisms or vaccines remains an important area of research and has public health implications. GBS has also been reported rarely in patients with underlying systemic diseases and immunocompromised states and although the exact mechanism is yet to be established, increased susceptibility to known infectious triggers should be considered most likely.
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Affiliation(s)
- Benjamin R Wakerley
- Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore.
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22
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Abstract
Peripheral nerve disorders are associated with all stages of HIV infection. Distal sensory polyneuropathy is characterised by often-disabling pain that is difficult to treat. It is prevalent in both high-income and low-income settings. In low-income settings, use of potentially neurotoxic antiretrovirals, which are inexpensive and widely available, contributes substantially to incidence. Research has focused on identification of factors that predict risk of distal sensory polyneuropathy and elucidation of the multifactorial mechanisms behind pathogenesis. Sensorimotor polyneuropathies and polyradiculopathies are less frequent than distal sensory polyneuropathy, but still occur in low-income settings and have potentially devastating consequences. However, many of these diseases can be treated successfully with a combination of antiretroviral and immune-modulating therapies. To distinguish between peripheral nerve disorders that have diverse, overlapping, and frequently atypical presentations can be challenging; a framework based on a clinicoanatomical approach might assist in the diagnosis and management of such disorders.
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Abstract
Peripheral neuropathies are the most common neurological manifestations occurring in HIV-infected individuals. Distal symmetrical sensory neuropathy is the most common form encountered today and is one of the few that are specific to HIV infection or its treatment. The wide variety of other neuropathies is akin to the neuropathies seen in the general population and should be managed accordingly. In the pre-ART era, neuropathies were categorized according to the CD4 count and HIV viral load. In the early stages of HIV infection when CD4 count is high, the inflammatory demyelinating neuropathies predominate and in the late stages with the decline of CD4 count opportunistic infection-related neuropathies prevail. That scenario has changed with the present almost universal use of ART (antiretroviral therapy). Hence, HIV-associated peripheral neuropathies are better classified according to their clinical presentations: distal symmetrical polyneuropathy, acute inflammatory demyelinating polyradiculoneuropathy (AIDP) and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), mononeuropathies, mononeuropathies multiplex and cranial neuropathies, autonomic neuropathy, lumbosacral polyradiculomyelopathy, and amyotrophic lateral sclerosis (ALS)-like motor neuropathy. Treated with ART, HIV-infected individuals are living longer and are at a higher risk of metabolic and age-related complications; moreover they are also prone to the potentially neurotoxic effects of ART. There are no epidemiological data regarding the incidence and prevalence of the peripheral neuropathies. In the pre-ART era, most data were from case reports, series of patients, and pooled autopsy data. At that time the histopathological evidence of neuropathies in autopsy series was almost 100%. In large prospective cohorts presently being evaluated, it has been found that 57% of HIV-infected individuals have distal symmetrical sensory neuropathy and 38% have neuropathic pain. It is now clear that distal symmetrical sensory neuropathy is caused predominantly by the ART's neurotoxic effect but may also be caused by the HIV itself. With a sizeable morbidity, the neuropathic pain caused by distal symmetrical sensory neuropathy is very difficult to manage; it is often necessary to change the ART regimen before deciding upon the putative role of HIV infection itself. If the change does not improve the pain, there are few options available; the most common drugs used for neuropathic pain are usually not effective. One is left with cannabis, which cannot be recommended as routine therapy, recombinant human nerve growth factor, which is unavailable, and topical capsaicin with its side-effects. Much has been done to and learned from HIV infection in humans; HIV-infected individuals, treated with ART, are now dying mostly from cardiovascular disease and non-AIDS-related cancers. It hence behooves us to find new approaches to mitigate the residual neurological morbidity that still impacts the quality of life of that population.
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Affiliation(s)
- Alberto Alain Gabbai
- Department of Neurology, UNIFESP-Escola Paulista de Medicina, São Paulo, Brazil.
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Eyer-Silva WDA, Salgado MCDF, Pinto JFDC, Ferry FRDA, Neves-Motta R, Azevedo MCVMD, Morais-de-Sá CA. Acute gouty arthritis as a manifestation of immune reconstitution inflammatory syndrome after initiation of antiretroviral therapy. Rev Inst Med Trop Sao Paulo 2012; 54:231-3. [DOI: 10.1590/s0036-46652012000400009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Accepted: 05/02/2012] [Indexed: 11/22/2022] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) in HIV-infected subjects initiating antiretroviral therapy most commonly involves new or worsening manifestations of previously subclinical or overt infectious diseases. Reports of non-infectious IRIS are much less common but represent important diagnostic and treatment challenges. We report on a 34-year-old HIV-infected male patient with no history of gout who developed acute gouty arthritis in a single joint one month after initiating highly active antiretroviral therapy.
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Pathogenesis of the immune reconstitution inflammatory syndrome in HIV-infected patients. Curr Opin Infect Dis 2012; 25:312-20. [PMID: 22562000 DOI: 10.1097/qco.0b013e328352b664] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW The immune reconstitution inflammatory syndrome (IRIS) is an important clinical complication in HIV-infected patients initiating antiretroviral therapy. This review focuses on the latest literature pertaining to the pathogenesis of IRIS. RECENT FINDINGS The clinical manifestations of IRIS are heterogeneous due to the variety of opportunistic infections that are associated with this inflammatory syndrome. However, the disproportionate inflammation is a defining hallmark for which common mechanisms are suspected. Lymphopenia-induced proliferation in the context of systemic immune activation, presence of high antigenic exposure and a wider availability of interleukin-7 contribute to the exacerbated immune response underlying IRIS. Defect in pathogen clearance by phagocytes might favor high pathogen burden, which in turn is thought to activate both innate immune cells and pathogen-specific T cells upon correction of the CD4 T-cell lymphopenia, predisposing to IRIS. This common scenario might be further invigorated by functional impairments among regulatory T cells. SUMMARY Further insight into the cellular mechanisms driving IRIS is urgently needed. Understanding the relative contribution of distinct effector and regulatory T-cell subsets, and innate immune components to IRIS is required to inspire future therapeutic approaches.
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Abstract
Antiretroviral therapy (ART) initiation in HIV-infected patients leads to recovery of CD4+T cell numbers and restoration of protective immune responses against a wide variety of pathogens, resulting in reduction in the frequency of opportunistic infections and prolonged survival. However, in a subset of patients, dysregulated immune response after initiation of ART leads to the phenomenon of immune reconstitution inflammatory syndrome (IRIS). The hallmark of the syndrome is paradoxical worsening of an existing infection or disease process or appearance of a new infection/disease process soon after initiation of therapy. The overall incidence of IRIS is unknown, but is dependent on the population studied and the burden of underlying opportunistic infections. The immunopathogenesis of the syndrome is unclear and appears to be result of unbalanced reconstitution of effector and regulatory T-cells, leading to exuberant inflammatory response in patients receiving ART. Biomarkers, including interferon-γ (INF-γ), tumour necrosis factor-α (TNF-α), C-reactive protein (CRP) and inter leukin (IL)-2, 6 and 7, are subject of intense investigation at present. The commonest forms of IRIS are associated with mycobacterial infections, fungi and herpes viruses. Majority of patients with IRIS have a self-limiting disease course. ART is usually continued and treatment for the associated condition optimized. The overall mortality associated with IRIS is low; however, patients with central nervous system involvement with raised intracranial pressures in cryptococcal and tubercular meningitis, and respiratory failure due to acute respiratory distress syndrome (ARDS) have poor prognosis and require aggressive management including corticosteroids. Paradigm shifts in management of HIV with earlier initiation of ART is expected to decrease the burden of IRIS in developed countries; however, with enhanced rollout of ART in recent years and the enormous burden of opportunistic infections in developing countries like India, IRIS is likely to remain an area of major concern.
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Affiliation(s)
- Surendra K Sharma
- Department of Internal Medicine, All India Institute of Medical Sciences, New Delhi, India.
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27
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Guillain-Barré Syndrome with Fatal Outcome during HIV-1-Seroconversion: A Case Report. Case Rep Infect Dis 2011; 2011:972096. [PMID: 22567484 PMCID: PMC3336224 DOI: 10.1155/2011/972096] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2011] [Accepted: 06/21/2011] [Indexed: 11/22/2022] Open
Abstract
Guillain-Barré syndrome (GBS) is an acute or subacute peripheral polyneuropathy characterized by symmetrical muscle weakness. Its occurrence has been reported during acute HIV seroconversion since 1985. Among HIV-infected subjects, GBS has generally a favourable outcome. We report a case of GBS with fatal outcome during HIV seroconversion.
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Proal AD, Albert PJ, Blaney GP, Lindseth IA, Benediktsson C, Marshall TG. Immunostimulation in the era of the metagenome. Cell Mol Immunol 2011; 8:213-25. [PMID: 21278764 PMCID: PMC4076734 DOI: 10.1038/cmi.2010.77] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Accepted: 12/15/2010] [Indexed: 12/15/2022] Open
Abstract
Microbes are increasingly being implicated in autoimmune disease. This calls for a re-evaluation of how these chronic inflammatory illnesses are routinely treated. The standard of care for autoimmune disease remains the use of medications that slow the immune response, while treatments aimed at eradicating microbes seek the exact opposite-stimulation of the innate immune response. Immunostimulation is complicated by a cascade of sequelae, including exacerbated inflammation, which occurs in response to microbial death. Over the past 8 years, we have collaborated with American and international clinical professionals to research a model-based treatment for inflammatory disease. This intervention, designed to stimulate the innate immune response, has required a reevaluation of disease progression and amelioration. Paramount is the inherent conflict between palliation and microbicidal efficacy. Increased microbicidal activity was experienced as immunopathology-a temporary worsening of symptoms. Further studies are needed, but they will require careful planning to manage this immunopathology.
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Martin-Blondel G, Delobel P, Blancher A, Massip P, Marchou B, Liblau RS, Mars LT. Pathogenesis of the immune reconstitution inflammatory syndrome affecting the central nervous system in patients infected with HIV. Brain 2011; 134:928-46. [DOI: 10.1093/brain/awq365] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Capers KN, Turnacioglu S, Leshner RT, Crawford JR. Antiretroviral therapy-associated acute motor and sensory axonal neuropathy. Case Rep Neurol 2011; 3:1-6. [PMID: 21327178 PMCID: PMC3037986 DOI: 10.1159/000322573] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Guillain-Barré syndrome (GBS) has been reported in HIV-infected patients in association with the immune reconstitution syndrome whose symptoms can be mimicked by highly active antiretroviral therapy (HAART)-mediated mitochondrial toxicity. We report a case of a 17-year-old, HIV-infected patient on HAART with a normal CD4 count and undetectable viral load, presenting with acute lower extremity weakness associated with lactatemia. Electromyography/nerve conduction studies revealed absent sensory potentials and decreased compound muscle action potentials, consistent with a diagnosis of acute motor and sensory axonal neuropathy. Lactatemia resolved following cessation of HAART; however, neurological deficits minimally improved over several months in spite of immune modulatory therapy. This case highlights the potential association between HAART, mitochondrial toxicity and acute axonal neuropathies in HIV-infected patients, distinct from the immune reconstitution syndrome.
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Affiliation(s)
- Kimberly N Capers
- Department of Neurology, Children's National Medical Center, The George Washington University School of Medicine, Washington, D.C
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31
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Nishijima T, Tsukada K, Takeuchi S, Chiba A, Honda M, Teruya K, Gatanaga H, Kikuchi Y, Oka S. Antiretroviral therapy for treatment-naïve chronic HIV-1 infection with an axonal variant of Guillain-Barré syndrome positive for anti-ganglioside antibody: a case report. Intern Med 2011; 50:2427-9. [PMID: 22001481 DOI: 10.2169/internalmedicine.50.5883] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Guillain-Barré syndrome sometimes manifests as immune reconstitution inflammatory syndrome. We report a treatment-naïve male with chronic HIV-1 infection who presented with an axonal variant of Guillain-Barré syndrome. Antiretroviral therapy commenced one month later and no rapid improvement or deterioration of tetraparesis was noted. This is the first report that describes the detection and serial measurements of anti-ganglioside antibody in a patient with HIV infection. This case suggests a limited role for T-cell immunity in the production of anti-ganglioside antibody and the pathogenesis of axonal variants, since the antiretroviral therapy-induced improvement in T-cell immunity neither re-elevated anti-ganglioside antibody titer nor worsened tetraparesis.
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Steiner I, Rosenberg G, Wirguin I. Transient immunosuppression: a bridge between infection and the atypical autoimmunity of Guillain-Barré syndrome? Clin Exp Immunol 2010; 162:32-40. [PMID: 20735441 DOI: 10.1111/j.1365-2249.2010.04223.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Guillain-Barré syndrome (GBS) is an acute, usually monophasic, disorder of the peripheral nervous system that is assumed to be of immune-mediated pathogenesis. However, several clinical features and experimental findings of GBS are uncharacteristic for an immune-mediated disorder and set this condition apart from other disorders with a putative immune-mediated pathogenesis. These features include, among others, the monophasic nature of GBS, the lack of response to immunosuppressive (unlike immunomodulatory) therapy, the absence of a typical association with immunogenetic background and the inability to establish a valid and relevant animal model. We suggest a comprehensive hypothesis for the pathogenesis of GBS that is based on the assumption that the condition is due to a transient (or occasionally chronic) immune deficiency, as in most cases GBS follows an infection with pathogens known to induce immunosuppression. Such infections may be followed by breakdown of immune tolerance and induction of an immune attack on peripheral nerves. Mounting of the immune-mediated assault might be triggered either by the same infective pathogen or by secondary infection. Clearance of the infection and resumption of a normal immune response and tolerance eventually terminate the immune-mediated damage to the peripheral nerves and enable recovery. This hypothesis assumes that the entire sequence of events that culminates in GBS is due to transient exogenous factors and excludes a significant role for inherent host susceptibility, which explains the monophasic nature of the disorder.
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Affiliation(s)
- I Steiner
- Department of Neurology, Rabin Medical Center, Petah Tiqva, D-Pharm Ltd, Kiryat Weizmann Science Park, Rehovot, Israel.
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Complex regional pain syndrome in a HIV seropositive patient starting antiretroviral therapy. J Clin Rheumatol 2010; 15:371-2. [PMID: 20009979 DOI: 10.1097/rhu.0b013e3181be230a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Johnson T, Nath A. Neurological complications of immune reconstitution in HIV-infected populations. Ann N Y Acad Sci 2009; 1184:106-20. [DOI: 10.1111/j.1749-6632.2009.05111.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Reyes-Corcho A, Bouza-Jiménez Y. [Human immunodeficiency virus and AIDS-associated immune reconstitution syndrome. State of the art]. Enferm Infecc Microbiol Clin 2009; 28:110-21. [PMID: 19632745 DOI: 10.1016/j.eimc.2009.03.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2008] [Revised: 03/20/2009] [Accepted: 03/27/2009] [Indexed: 01/27/2023]
Abstract
Since the arrival of highly active antiretroviral therapy (HAART), immune reconstitution syndrome (IRS) has become an increasingly more frequent complication in patients with human immunodeficiency virus (HIV) infection. This article presents a review of the available evidence on this subject, indexed in MEDLINE-PUBMED, BVS-BIREME, and BioMed Central. The review covers the definition, epidemiology, classification, and diagnostic criteria related to IRS. In addition, the clinical particularities of the most frequent etiologies are described, and a proposal for a therapeutic approach is formulated. The prognosis and future implications of this syndrome in the epidemiology of some infectious illnesses in the HIV-positive population are included. Several unresolved aspects are mentioned, such as those related to the pathophysiology of the condition, use of biomarkers for the diagnosis, and the need for evidence-based therapeutic algorithms to enable standardization of treatment for these patients.
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Affiliation(s)
- Andrés Reyes-Corcho
- Servicio de Enfermedades Infecciosas, Hospital Universitario Dr. Gustavo Aldereguía Lima, Cienfuegos, Cuba
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Ferrari S, Lanzafame M, Faggian F, Malena M, Cruciani M, Cauallaro T, Rizzutol N, Concia E, Vento S. Painful Neuropathy Vasculitis in 2 Patients with Long-Standing Human Immunodeficiency Virus-1 Infection. ACTA ACUST UNITED AC 2009; 36:392-3. [PMID: 15287390 DOI: 10.1080/00365540410019093] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
We describe 2 most unusual cases of distal symmetrical painful polyneuropathy in patients with long-standing HIV-1 infection well controlled by HAART. Sural nerve biopsies revealed vasculitis in both cases and steroid therapy led to resolution of symptoms not influenced by analgesics and anti-inflammatory drugs. These unusual cases outline the importance of nerve biopsies in order to reach a diagnosis.
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Affiliation(s)
- Sergio Ferrari
- Sections of Clinical Neurology, Department of Neurological and Visual Sciences, University of Verona, Verona, Italy
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Abstract
Antiretroviral therapy (ART) inhibits HIV replication, allowing recovery of CD4+ T cell numbers and the restoration of immune function; its introduction has led to improved outcomes for individuals with HIV infection. However, it has been observed that some individuals responding to ART experience a clinical deterioration with symptoms and signs of an inflammatory illness. Immune reconstitution inflammatory syndrome (IRIS) results from pathological immune responses occurring during immune reconstitution. IRIS is best considered a group of disorders with a wide range of clinical manifestations, incorporating disease resulting from pathological inflammation to pathogens, immune-mediated inflammatory disease and autoimmune disease. Clinical effects range from a mild, self-limiting illness to severe morbidity and mortality. Clinicians working in the field of HIV medicine can expect to encounter individuals with IRIS. In this review, we discuss definitions, describe clinical presentations, summarize research relating to pathogenesis and identify risk factors, preventive and management strategies.
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Affiliation(s)
- J W T Elston
- Department of Infection and Tropical Medicine, Castle Hill Hospital, Cottingham, East Yorkshire HU16 5JQ, UK
| | - H Thaker
- Department of Infection and Tropical Medicine, Castle Hill Hospital, Cottingham, East Yorkshire HU16 5JQ, UK
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Sloan DJ, Nicolson A, Miller ARO, Beeching NJ, Beadsworth MBJ. Human immunodeficiency virus seroconversion presenting with acute inflammatory demyelinating polyneuropathy: a case report. J Med Case Rep 2008; 2:370. [PMID: 19055816 PMCID: PMC2629480 DOI: 10.1186/1752-1947-2-370] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2008] [Accepted: 12/04/2008] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Acute Human Immunodeficiency Virus infection is associated with a range of neurological conditions. Guillain-Barré syndrome is a rare presentation; acute inflammatory demyelinating polyneuropathy is the commonest form of Guillain-Barré syndrome. Acute inflammatory demyelinating polyneuropathy has occasionally been reported in acute Immunodeficiency Virus infection but little data exists on frequency, management and outcome. CASE PRESENTATION We describe an episode of Guillain-Barré syndrome presenting as acute inflammatory demyelinating polyneuropathy in a 30-year-old man testing positive for Immunodeficiency Virus, probably during acute seroconversion. Clinical suspicion was confirmed by cerebrospinal fluid analysis and nerve conduction studies. Rapid clinical deterioration prompted intravenous immunoglobulin therapy and early commencement of highly active anti-retroviral therapy. All symptoms resolved within nine weeks. CONCLUSION Unusual neurological presentations in previously fit patients are an appropriate indication for Immunodeficiency-Virus testing. Highly active anti-retroviral therapy with adequate penetration of the central nervous system should be considered as an early intervention, alongside conventional therapies such as intravenous immunoglobulin.
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Affiliation(s)
- Derek J Sloan
- Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK.
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Dhasmana DJ, Dheda K, Ravn P, Wilkinson RJ, Meintjes G. Immune reconstitution inflammatory syndrome in HIV-infected patients receiving antiretroviral therapy : pathogenesis, clinical manifestations and management. Drugs 2008; 68:191-208. [PMID: 18197725 DOI: 10.2165/00003495-200868020-00004] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The use of antiretroviral therapy (ART) to treat HIV infection, by restoring CD4+ cell count and immune function, is associated with significant reductions in morbidity and mortality. Soon after ART initiation, there is a rapid phase of restoration of pathogen-specific immunity. In certain patients, this results in inflammatory responses that may result in clinical deterioration known as 'the immune reconstitution inflammatory syndrome' (IRIS). IRIS may be targeted at viable infective antigens, dead or dying infective antigens, host antigens, tumour antigens and other antigens, giving rise to a heterogeneous range of clinical manifestations. The commonest forms of IRIS are associated with mycobacterial infections, fungi and herpes viruses. In most patients, ART should be continued and treatment for the associated condition optimized, and there is anecdotal evidence for the use of corticosteroids in patients who are severely affected. In this review, we discuss research relating to pathogenesis, the range of clinical manifestations, treatment options and prevention issues.
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Affiliation(s)
- Devesh J Dhasmana
- Department of Respiratory Medicine, Harefield Hospital, Middlesex, UK
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Singh N, Perfect JR. Immune reconstitution syndrome and exacerbation of infections after pregnancy. Clin Infect Dis 2007; 45:1192-9. [PMID: 17918082 DOI: 10.1086/522182] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2007] [Accepted: 07/21/2007] [Indexed: 11/03/2022] Open
Abstract
Pregnancy is a state of subtle immunosuppression characterized by physiologic suppression of proinflammatory host responses that are meant to promote embryonic implantation. Rapid reversal of these changes and a rebound of inflammatory responses during the postpartum period can result in quiescent or latent infection manifesting as symptomatic disease. Infections due to several microbial pathogens and noninfectious diseases with an autoimmune basis have been shown to worsen or begin during the postpartum period. Awareness that symptoms resulting from immune reconstitution can occur in any host with a rapidly changing immunologic repertoire, including women in the postpartum phase, is a critical first step in fully understanding this phenomenon. Future studies to discern the precise pathophysiologic basis of immune reconstitution, to identify pregnant women at risk, and to determine markers that may be diagnostically helpful have significant implications for optimizing treatment of these patients.
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Affiliation(s)
- Nina Singh
- Veterans Affairs Medical Center, Infectious Diseases Section, Pittsburgh, PA 15240, USA.
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Elevated anti-sulfatide antibodies in Guillain-Barré syndrome in T cell depleted at end-stage AIDS. J Neuroimmunol 2007; 188:143-5. [PMID: 17602755 DOI: 10.1016/j.jneuroim.2007.05.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2007] [Revised: 05/22/2007] [Accepted: 05/31/2007] [Indexed: 10/23/2022]
Abstract
A 38-year-old man developed the Guillain-Barré syndrome (GBS) associated with untreated end-stage AIDS and CD4+ lymphocyte count of 3 cells/mm(3). The patient had serum high titer anti-sulfatide antibodies and responded well to infusion of immunoglobulin. The data suggest that elevated levels of anti-sulfatide antibodies may play a role in the pathogenesis of GBS in this patient, although a direct neurotropic effect of HIV virus cannot be excluded.
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Murdoch DM, Venter WDF, Van Rie A, Feldman C. Immune reconstitution inflammatory syndrome (IRIS): review of common infectious manifestations and treatment options. AIDS Res Ther 2007; 4:9. [PMID: 17488505 PMCID: PMC1871602 DOI: 10.1186/1742-6405-4-9] [Citation(s) in RCA: 175] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2007] [Accepted: 05/08/2007] [Indexed: 11/24/2022] Open
Abstract
The immune reconstitution inflammatory syndrome (IRIS) in HIV-infected patients initiating antiretroviral therapy (ART) results from restored immunity to specific infectious or non-infectious antigens. A paradoxical clinical worsening of a known condition or the appearance of a new condition after initiating therapy characterizes the syndrome. Potential mechanisms for the syndrome include a partial recovery of the immune system or exuberant host immunological responses to antigenic stimuli. The overall incidence of IRIS is unknown, but is dependent on the population studied and its underlying opportunistic infectious burden. The infectious pathogens most frequently implicated in the syndrome are mycobacteria, varicella zoster, herpesviruses, and cytomegalovirus (CMV). No single treatment option exists and depends on the underlying infectious agent and its clinical presentation. Prospective cohort studies addressing the optimal screening and treatment of opportunistic infections in patients eligible for ART are currently being conducted. These studies will provide evidence for the development of treatment guidelines in order to reduce the burden of IRIS. We review the available literature on the pathogenesis and epidemiology of IRIS, and present treatment options for the more common infectious manifestations of this diverse syndrome and for manifestations associated with a high morbidity.
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Affiliation(s)
- David M Murdoch
- Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham North Carolina, USA
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- CB#7435, 2104-H McGavran-Greenberg Hall, University of North Carolina, School of Public Health, Chapel Hill, NC 27599-7435, USA
| | - Willem DF Venter
- Reproductive Health & HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Annelies Van Rie
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Charles Feldman
- Division of Pulmonology, Department of Medicine, Johannesburg Hospital and University of the Witwatersrand, Johannesburg, South Africa
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French MA. Disorders of immune reconstitution in patients with HIV infection responding to antiretroviral therapy. Curr HIV/AIDS Rep 2007; 4:16-21. [PMID: 17338856 DOI: 10.1007/s11904-007-0003-z] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Patients with HIV infection who were very immunodeficient before achieving a virologic response to antiretroviral therapy (ART) may experience various disorders of immune reconstitution. Immune restoration disease occurs in approximately 10% to 50% of patients and results from the restoration of a pathogen-specific immune response that causes immunopathology and presents as tissue inflammation or cellular proliferative disease. Opportunistic infections occur in no more than 5% of patients, but approximately one half of these patients have higher than expected CD4 T-cell counts and appear to have residual immune dysfunction. Autoimmune disease may arise because the reconstituted immune system confers an increased susceptibility to immune dysregulation but there may be different mechanisms because Graves' disease presents after a median time of about 2 years of ART whereas systemic lupus erythematosus presents earlier. Persistent CD4 T-cell deficiency (< 500/microL) affects up to 60% of patients and appears to reflect depletion of the naïve T-cell pool that results from low production and/or increased turnover of cells.
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Affiliation(s)
- Martyn A French
- Department of Clinical Immunology, Royal Perth Hospital, GPO Box X2213, Perth, WA 6847, Australia.
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Houff SA, Major EO. Neuropharmacology of HIV/AIDS. HANDBOOK OF CLINICAL NEUROLOGY 2007; 85:319-364. [PMID: 18808990 DOI: 10.1016/s0072-9752(07)85019-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Hickman SJ, Sanyal A, Manji H, Groves MJ, Giovannoni G. "Double whammy" neuropathy: a 37-year-old woman with burning and weakness in both legs. Lancet Neurol 2006; 5:632-6. [PMID: 16781993 DOI: 10.1016/s1474-4422(06)70498-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Simon J Hickman
- Department of Neurology, The National Hospital for Neurology and Neurosurgery, London, UK.
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Ferrari S, Vento S, Monaco S, Cavallaro T, Cainelli F, Rizzuto N, Temesgen Z. Human immunodeficiency virus-associated peripheral neuropathies. Mayo Clin Proc 2006; 81:213-9. [PMID: 16471077 DOI: 10.4065/81.2.213] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Peripheral neuropathy has emerged as the most common neurologic complication of human immunodeficiency virus (HIV) infection. It will continue to play an Important role in HIV Infection given the fact that HIV-infected Individuals are living longer, are at risk of long-term metabolic complications, and face an Increasing exposure to potentially neurotoxic antiretroviral drugs. We review the various types of peripheral neuropathy that have been associated with HIV infection, including distal symmetrical polyneuropathy, toxic neuropathy from antiretroviral drugs, diffuse infiltrative lymphocytosis syndrome, inflammatory demyelinating polyneuropathies, multifocal mononeuropathies, and progressive polyradiculopathy.
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Affiliation(s)
- Sergio Ferrari
- Department of Neurological and Visual Sciences, Section of Neurology, University of Verona, Verona, Italy
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Trottier B, Walmsley S, Reynes J, Piliero P, O'Hearn M, Nelson M, Montaner J, Lazzarin A, Lalezari J, Katlama C, Henry K, Cooper D, Clotet B, Arastéh K, Delfraissy JF, Stellbrink HJ, Lange J, Kuritzkes D, Eron JJ, Cohen C, Kinchelow T, Bertasso A, Labriola-Tompkins E, Shikhman A, Atkins B, Bourdeau L, Natale C, Hughes F, Chung J, Guimaraes D, Drobnes C, Bader-Weder S, Demasi R, Smiley L, Salgo MP. Safety of enfuvirtide in combination with an optimized background of antiretrovirals in treatment-experienced HIV-1-infected adults over 48 weeks. J Acquir Immune Defic Syndr 2006; 40:413-21. [PMID: 16280695 DOI: 10.1097/01.qai.0000185313.48933.2c] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Antiretroviral tolerability is a critical factor contributing to treatment outcome. The T-20 Versus Optimized Background Regimen Only (TORO) studies assessed the safety and efficacy of enfuvirtide in treatment-experienced HIV-1-infected patients. METHODS A total of 997 patients were randomized at a 2:1 ratio to an optimized background antiretroviral regimen plus enfuvirtide (n = 663) or an optimized background regimen alone (control group; n = 334). Control patients could switch to enfuvirtide on virologic failure. RESULTS In total, 26.5% of patients randomized to enfuvirtide and 36.6% to the control group discontinued study treatment before week 48; the percentage of patients withdrawn for safety reasons (including adverse events [AEs], deaths, and laboratory abnormalities) was 14.0% in the enfuvirtide group and 11.6% in the control group. Injection site reactions (ISRs) occurred in 98% of enfuvirtide patients and led to treatment discontinuation in 4.4%. Treatment-related (defined as possibly, probably, or remotely) AE rates per 100 patient-years were lower with enfuvirtide (96.2) than in the control group (149.9); diarrhea, nausea, and fatigue, the most frequently reported AEs, were significantly less frequent with enfuvirtide than in the control group. Pneumonia was significantly more frequent in patients treated with enfuvirtide (6.7 vs. 0.6 events per 100 patient-years), although the incidence was within expected ranges for this population. Lymphadenopathy was also higher in enfuvirtide-treated patients (7.1 vs. 1.2 events per 100 patient-years) for control patients. CONCLUSION The addition of enfuvirtide to an optimized background regimen does not exacerbate AEs commonly associated with antiretrovirals. ISRs limited treatment in <5% of patients.
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Puthanakit T, Oberdorfer P, Akarathum N, Wannarit P, Sirisanthana T, Sirisanthana V. Immune reconstitution syndrome after highly active antiretroviral therapy in human immunodeficiency virus-infected thai children. Pediatr Infect Dis J 2006; 25:53-8. [PMID: 16395104 PMCID: PMC1924530 DOI: 10.1097/01.inf.0000195618.55453.9a] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND There is little information about the immune reconstitution syndrome (IRS) in children, especially from resource-poor countries. OBJECTIVE To determine the incidence and spectrum of IRS in advanced stage human immunodeficiency virus (HIV)-infected children after initiation of highly active antiretroviral therapy (HAART). METHODS Between May 2002 and April 2004, 153 symptomatic HIV-infected children who had CD4 lymphocyte percentage < or =15% initiated HAART in a national antiretroviral drug access program. All patients were followed for 48 weeks. In this study, IRS was defined as a disease event caused by microorganisms or conditions previously reported to be associated with IRS in patients having immunologic and/or virologic response to HAART. RESULTS The incidence of IRS was 19% (95% confidence interval, 13.1-26.1). The median time of onset was 4 weeks after start of HAART (range, 2-31). There were 32 episodes of IRS, including 14 caused by mycobacterial organisms, 7 by varicella-zoster virus, 7 by herpes simplex virus, 3 by Cryptococcus neoformans and 1 episode of Guillain-Barré syndrome. Patients who had IRS develop had lower baseline CD4 lymphocyte percentages compared with those who did not (P = 0.02). CONCLUSIONS IRS is common among HIV-infected children who received HAART in their advanced stage of disease. Educational programs for patients and health care workers on recognizing and treating these conditions should be integrated into antiretroviral treatment access programs.
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Gardner EM, Connick E. Illness of immune reconstitution: Recognition and management. Curr Infect Dis Rep 2004; 6:483-493. [PMID: 15538986 DOI: 10.1007/s11908-004-0068-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Some individuals who initiate highly active antiretroviral therapy (HAART) develop new or worsening opportunistic infections or malignancies despite improvements in surrogate markers of HIV-1 infection. These events of paradoxical clinical worsening, also known as immune reconstitution syndromes (IRS), are increased in individuals with prior opportunistic infections or low CD4+ T-cell nadirs. They are thought to result from reconstitution of the immune system's ability to recognize pathogens or tumor antigens that were previously present, but clinically asymptomatic. There is no consensus regarding the diagnostic criteria or pathogenesis of IRS. Knowledge of their presentation and treatment is largely based on case reports. With the introduction of HAART into resource-limited settings, it is likely that significantly more and distinct forms of IRS will be observed. Prospective studies of the incidence and treatment of IRS in multiple settings are critical to better understand their pathogenesis and optimal management.
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Affiliation(s)
- Edward M Gardner
- Division of Infectious Diseases, University of Colorado Health Sciences Center, 4200 East 9th Avenue, Box B168, Denver, CO 80262, USA.
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Abstract
Suppression of HIV replication by highly active antiretroviral therapy (HAART) often restores protective pathogen-specific immune responses, but in some patients the restored immune response is immunopathological and causes disease [immune restoration disease (IRD)]. Infections by mycobacteria, cryptococci, herpesviruses, hepatitis B and C virus, and JC virus are the most common pathogens associated with infectious IRD. Sarcoid IRD and autoimmune IRD occur less commonly. Infectious IRD presenting during the first 3 months of therapy appears to reflect an immune response against an active (often quiescent) infection by opportunistic pathogens whereas late IRD may result from an immune response against the antigens of non-viable pathogens. Data on the immunopathogenesis of IRD is limited but it suggests that immunopathogenic mechanisms are determined by the pathogen. For example, mycobacterial IRD is associated with delayed-type hypersensitivity responses to mycobacterial antigens whereas there is evidence of a CD8 T-cell response in herpesvirus IRD. Furthermore, the association of different cytokine gene polymorphisms with mycobacterial or herpesvirus IRD provides evidence of different pathogenic mechanisms as well as indicating a genetic susceptibility to IRD. Differentiation of IRD from an opportunistic infection is important because IRD indicates a successful, albeit undesirable, effect of HAART. It is also important to differentiate IRD from drug toxicity to avoid unnecessary cessation of HAART. The management of IRD often requires the use of anti-microbial and/or anti-inflammatory therapy. Investigation of strategies to prevent IRD is a priority, particularly in developing countries, and requires the development of risk assessment methods and diagnostic criteria.
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Affiliation(s)
- Martyn A French
- Department of Clinical Immunology and Biochemical Genetics, Royal Perth Hospital and School of Surgery and Pathology, University of Western Australia, Perth, Australia.
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