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Chang CC, Harrison TS, Bicanic TA, Chayakulkeeree M, Sorrell TC, Warris A, Hagen F, Spec A, Oladele R, Govender NP, Chen SC, Mody CH, Groll AH, Chen YC, Lionakis MS, Alanio A, Castañeda E, Lizarazo J, Vidal JE, Takazono T, Hoenigl M, Alffenaar JW, Gangneux JP, Soman R, Zhu LP, Bonifaz A, Jarvis JN, Day JN, Klimko N, Salmanton-García J, Jouvion G, Meya DB, Lawrence D, Rahn S, Bongomin F, McMullan BJ, Sprute R, Nyazika TK, Beardsley J, Carlesse F, Heath CH, Ayanlowo OO, Mashedi OM, Queiroz-Telles Filho F, Hosseinipour MC, Patel AK, Temfack E, Singh N, Cornely OA, Boulware DR, Lortholary O, Pappas PG, Perfect JR. Global guideline for the diagnosis and management of cryptococcosis: an initiative of the ECMM and ISHAM in cooperation with the ASM. THE LANCET. INFECTIOUS DISEASES 2024; 24:e495-e512. [PMID: 38346436 DOI: 10.1016/s1473-3099(23)00731-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/02/2023] [Accepted: 11/13/2023] [Indexed: 03/21/2024]
Abstract
Cryptococcosis is a major worldwide disseminated invasive fungal infection. Cryptococcosis, particularly in its most lethal manifestation of cryptococcal meningitis, accounts for substantial mortality and morbidity. The breadth of the clinical cryptococcosis syndromes, the different patient types at-risk and affected, and the vastly disparate resource settings where clinicians practice pose a complex array of challenges. Expert contributors from diverse regions of the world have collated data, reviewed the evidence, and provided insightful guideline recommendations for health practitioners across the globe. This guideline offers updated practical guidance and implementable recommendations on the clinical approaches, screening, diagnosis, management, and follow-up care of a patient with cryptococcosis and serves as a comprehensive synthesis of current evidence on cryptococcosis. This Review seeks to facilitate optimal clinical decision making on cryptococcosis and addresses the myriad of clinical complications by incorporating data from historical and contemporary clinical trials. This guideline is grounded on a set of core management principles, while acknowledging the practical challenges of antifungal access and resource limitations faced by many clinicians and patients. More than 70 societies internationally have endorsed the content, structure, evidence, recommendation, and pragmatic wisdom of this global cryptococcosis guideline to inform clinicians about the past, present, and future of care for a patient with cryptococcosis.
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Affiliation(s)
- Christina C Chang
- Department of Infectious Diseases, Alfred Hospital, Melbourne, VIC, Australia; Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, VIC, Australia; Centre for the AIDS Programme of Research in South Africa, Durban, South Africa.
| | - Thomas S Harrison
- Institute of Infection and Immunity, St George's University London, London, UK; Clinical Academic Group in Infection and Immunity, St George's University Hospitals NHS Foundation Trust, London, UK; Medical Research Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Tihana A Bicanic
- Institute of Infection and Immunity, St George's University London, London, UK; Clinical Academic Group in Infection and Immunity, St George's University Hospitals NHS Foundation Trust, London, UK; Medical Research Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Methee Chayakulkeeree
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Tania C Sorrell
- Sydney Infectious Diseases Institute, University of Sydney, Sydney, NSW, Australia; Department of Infectious Diseases, Westmead Hospital, Westmead, NSW, Australia
| | - Adilia Warris
- Medical Research Centre for Medical Mycology, University of Exeter, Exeter, UK; Department of Infectious Diseases, Great Ormond Street Hospital, London, UK
| | - Ferry Hagen
- Faculty of Science, Institute for Biodiversity and Ecosystem Dynamics, University of Amsterdam, Amsterdam, Netherlands; Department of Medical Mycology, Westerdijk Fungal Biodiversity Institute, Utrecht, Netherlands; Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Andrej Spec
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Rita Oladele
- College of Medicine, University of Lagos, Lagos, Nigeria
| | - Nelesh P Govender
- Institute of Infection and Immunity, St George's University London, London, UK; Medical Research Centre for Medical Mycology, University of Exeter, Exeter, UK; Department of Clinical Microbiology and Infectious Diseases, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Sharon C Chen
- Sydney Infectious Diseases Institute, University of Sydney, Sydney, NSW, Australia; Department of Infectious Diseases, Westmead Hospital, Westmead, NSW, Australia; Centre for Infectious Diseases and Microbiology Laboratory Services, Institute for Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead, NSW, Australia
| | - Christopher H Mody
- Department of Microbiology, Immunology and Infectious Diseases, Department of Medicine, Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, Canada
| | - Andreas H Groll
- Infectious Disease Research Program, and Department of Pediatric Hematology/Oncology, University Children's Hospital, Münster, Germany; Center for Bone Marrow Transplantation, and Department of Pediatric Hematology/Oncology, University Children's Hospital, Münster, Germany
| | - Yee-Chun Chen
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan; National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Zhunan, Taiwan
| | - Michail S Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology & Microbiology, National Institute of Allergy & Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Alexandre Alanio
- Institut Pasteur, Centre National de Référence Mycoses Invasives et Antifongiques, Groupe de recherche Mycologie Translationnelle, Département de Mycologie, Université Paris Cité, Paris, France; Laboratoire de parasitologie-mycologie, AP-HP, Hôpital Saint-Louis, Université Paris Cité, Paris, France
| | | | - Jairo Lizarazo
- Department of Internal Medicine, Hospital Universitario Erasmo Meoz, Faculty of Health, Univesidad de Pamplona, Cúcuta, Colombia
| | - José E Vidal
- Departmento de Neurologia, Instituto de Infectologia Emílio Ribas, São Paulo, Brazil; Departamento de Moléstias Infecciosas e Parasitárias, Hospital das Clinicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; Instituto de Medicina Tropical, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Takahiro Takazono
- Department of Infectious Diseases, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan; Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Martin Hoenigl
- Division of Infectious Diseases, Translational Medical Mycology Research Unit, European Confederation of Medical Mycology Excellence Center for Medical Mycology, Medical University of Graz, Graz, Austria; BioTechMed, Graz, Austria
| | - Jan-Willem Alffenaar
- Sydney Infectious Diseases Institute, University of Sydney, Sydney, NSW, Australia; Department of Pharmacy, Westmead Hospital, Westmead, NSW, Australia; School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Jean-Pierre Gangneux
- Institute for Health, Environment and Work Research-Irset, Inserm UMR_S 1085, University of Rennes, Rennes, France; Laboratory for Parasitology and Mycology, Centre National de Référence Mycoses Invasives et Antifongiques LA Asp-C, University Hospital of Rennes, Rennes, France
| | - Rajeev Soman
- Jupiter Hospital, Pune, India; Deenanath Mangeshkar Hospital, Pune, India; Hinduja Hospital, Mumbai, India
| | - Li-Ping Zhu
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai China
| | - Alexandro Bonifaz
- Hospital General de México, Dermatology Service, Mycology section, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Jeremy N Day
- Department of Clinical Microbiology and Infection, Royal Devon and Exeter University Hospital NHS Trust, Exeter, UK
| | - Nikolai Klimko
- Department of Clinical Mycology, Allergy and Immunology, I Mechnikov North Western State Medical University, Staint Petersburg, Russia
| | - Jon Salmanton-García
- Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and Excellence Center for Medical Mycology, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Partner Site Bonn-Cologne, German Centre for Infection Research, Cologne, Germany
| | - Grégory Jouvion
- Histology and Pathology Unit, Ecole nationale vétérinaire d'Alfort, Maisons-Alfort, France; Dynamyc Team, Université Paris Est Créteil and Ecole nationale vétérinaire d'Alfort, Créteil, France
| | - David B Meya
- Infectious Diseases Institute, School of Medicine, College of Heath Sciences, Makerere University, Kampala, Uganda
| | - David Lawrence
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Sebastian Rahn
- Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and Excellence Center for Medical Mycology, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Partner Site Bonn-Cologne, German Centre for Infection Research, Cologne, Germany
| | - Felix Bongomin
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Brendan J McMullan
- Discipline of Paediatrics, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Department of Infectious Diseases, Sydney Children's Hospital, Randwick, Sydney, NSW, Australia
| | - Rosanne Sprute
- Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and Excellence Center for Medical Mycology, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Partner Site Bonn-Cologne, German Centre for Infection Research, Cologne, Germany
| | - Tinashe K Nyazika
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Justin Beardsley
- Sydney Infectious Diseases Institute, University of Sydney, Sydney, NSW, Australia; Department of Infectious Diseases, Westmead Hospital, Westmead, NSW, Australia
| | - Fabianne Carlesse
- Pediatric Department, Federal University of São Paulo, São Paulo, Brazil; Oncology Pediatric Institute-IOP-GRAACC, Federal Univeristy of São Paulo, São Paulo, Brazil
| | - Christopher H Heath
- Department of Microbiology, Fiona Stanley Hospital Network, PathWest Laboratory Medicine, Perth, WA, Australia; Department of Infectious Diseases, Fiona Stanley Hospital, Perth, WA, Australia; UWA Medical School, Internal Medicine, The University of Western Australia, Perth, WA, Australia
| | - Olusola O Ayanlowo
- Dermatology Unit, Department of Medicine, Lagos University Teaching Hospital, University of Lagos, Lagos, Nigeria
| | - Olga M Mashedi
- Centre for Respiratory Diseases Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Mina C Hosseinipour
- Department of Medicine, Division of Infectious Diseases, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA; UNC Project Malawi, Lilongwe, Malawi
| | - Atul K Patel
- Department of Infectious Diseases, Sterling Hospitals, Ahmedabad, India
| | - Elvis Temfack
- Africa Centers for Disease Control and Prevention, Addis Ababa, Ethiopia
| | - Nina Singh
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Oliver A Cornely
- Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and Excellence Center for Medical Mycology, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Partner Site Bonn-Cologne, German Centre for Infection Research, Cologne, Germany; Clinical Trials Centre Cologne, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Olivier Lortholary
- Université de Paris Cité, APHP, Service des Maladies Infectieuses et Tropicales, Hôpital Necker-Enfants Malades, Centre d'Infectiologie Necker-Pasteur, Institut Imagine, Paris, France; Institut Pasteur, CNRS, Unité de Mycologie Moléculaire, Centre National de Référence Mycoses Invasives et Antifongiques, UMR 2000, Paris, France
| | - Peter G Pappas
- Mycoses Study Group Central Unit, Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - John R Perfect
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, NC, USA; Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC, USA.
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Chang MH, Guo Y, Acbo A, Bao H, McSweeney T, Vo CA, Nori P. Antiretroviral Stewardship: Top 10 Questions Encountered by Stewardship Teams and Solutions to Optimize Therapy. Clin Ther 2024; 46:455-462. [PMID: 38704295 DOI: 10.1016/j.clinthera.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 03/26/2024] [Accepted: 04/04/2024] [Indexed: 05/06/2024]
Abstract
PURPOSE Infectious disease pharmacists and physicians overseeing antimicrobial stewardship programs possess expertise and often advanced certification in management of antiretrovirals to treat HIV. Stewardship programs are responsible for managing facility formularies and must stay up to date with the latest antiretrovirals, including once daily formulations and depot injectables. Furthermore, stewardship program members need to understand drug-interactions, short-, and long-term toxicities of these regimens, including dyslipidemia and cardiovascular effects. Patients receiving chronic antiretroviral therapy may present to the acute care, ambulatory care, and long-term care settings. Like other antimicrobials, audit-and-feedback, drug monitoring, and dose-optimization are often required to prevent antiretroviral associated medication errors and minimize resistance. METHODS A narrative review was conducted on antiretroviral stewardship, addressing common clinical questions encountered by stewardship teams and best practices to optimize antiretroviral therapy and reduce the risk for treatment interruptions, resistance, drug interactions, long term toxicities, and other adverse effects. FINDINGS People living with HIV are often hospitalized and treated by medical teams without formal HIV training. For this reason, these patients are at greater risk for medication errors during hospitalization and between transitions of care. Many opportunities are present for antiretroviral stewardship to mitigate these errors. Frequent updates to simplify HIV regimen, maintain select patients on fixed-dose combination tablets, and strategies to minimize drug interactions make it difficult for even the seasoned clinician to keep up regularly. IMPLICATIONS Despite the availability of free online HIV resources and progress made in HIV management, significant opportunities for antiretroviral stewardship remain. Implementing electronic order entry updates, formulary upgrades, and formal pharmacy renal dose adjustments to optimize antiretroviral therapy will help clinicians harness these opportunities. Dedicated time and expertise for antiretroviral stewardship as part of local antimicrobial stewardship programs are needed.
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Affiliation(s)
- Mei H Chang
- Department of Pharmacy, Montefiore Health System, Bronx, New York.
| | - Yi Guo
- Department of Pharmacy, Montefiore Health System, Bronx, New York
| | - Antoinette Acbo
- Department of Pharmacy, Montefiore Health System, Bronx, New York
| | - Hongkai Bao
- Department of Pharmacy, Montefiore Health System, Bronx, New York
| | | | - Christopher A Vo
- Division of Infectious Diseases, Department of Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, New York
| | - Priya Nori
- Division of Infectious Diseases, Department of Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, New York
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3
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Lu L, Ma Y, Cong Y, Zhou B, Chen Y, Niu J, He Y, Cao W, Li T. Comorbidity of Myasthenia gravis and Graves' disease as immune reconstitution-associated autoimmune disease in HIV infection: A case report and literature review. HIV Med 2024; 25:398-403. [PMID: 37990629 DOI: 10.1111/hiv.13584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/05/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Comorbidity of Myasthenia gravis (MG) and Graves' disease (GD) in treated HIV-infected individuals has rarely been described and little study has been done on the link between HIV-related immune reconstitution and autoimmune diseases occurring post antiretroviral therapy. CASE PRESENTATION Here we report on a 33-year-old Chinese man with HIV infection who had been virologically suppressed since 2018. The patient was diagnosed with GD and was treated in 2020. Early in 2022, he developed fluctuating weakness and fatigue involving the bilateral extraocular muscles and limbs. With a positive neostigmine test, he was considered to have MG, but showed a poor response to oral medication. After multiple failed medication attempts, a thymectomy was finally performed to resolve his symptoms. The consecutive onset of immunological events may have partially resulted from immune reconstitution after viral control. CONCLUSIONS This is a rare case of HIV-related immune reconstitution-associated autoimmune disease (IRAD) with comorbidity of MG and GD which was reported initially. Cooperation with multidisciplinary teams is essential to avoid misdiagnosis and to promote the overall health of HIV-infected patients.
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Affiliation(s)
- Lianfeng Lu
- Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yanan Ma
- Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yang Cong
- Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Baotong Zhou
- Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yeye Chen
- Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jingwen Niu
- Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yun He
- Department of Infectious Diseases, The Third People's Hospital of Shenzhen: Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China
| | - Wei Cao
- Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Taisheng Li
- Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- Department of Basic Medical Sciences, School of Medicine, Tsinghua University, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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Vakrakou AG, Brinia ME, Alexaki A, Koumasopoulos E, Stathopoulos P, Evangelopoulos ME, Stefanis L, Stadelmann-Nessler C, Kilidireas C. Multiple faces of multiple sclerosis in the era of highly efficient treatment modalities: Lymphopenia and switching treatment options challenges daily practice. Int Immunopharmacol 2023; 125:111192. [PMID: 37951198 DOI: 10.1016/j.intimp.2023.111192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 10/25/2023] [Accepted: 11/03/2023] [Indexed: 11/13/2023]
Abstract
The expanded treatment landscape in relapsing-remitting multiple sclerosis (MS) has resulted in highly effective treatment options and complexity in managing disease- or drug-related events during disease progression. Proper decision-making requires thorough knowledge of the immunobiology of MS itself and an understanding of the main principles behind the mechanisms that lead to secondary autoimmunity affecting organs other than the central nervous system as well as opportunistic infections. The immune system is highly adapted to both environmental and disease-modifying agents. Immune reconstitution following cell depletion or cell entrapment therapies eliminates pathogenic aspects of the disease but can also lead to distorted immune responses with harmful effects. Atypical relapses occur with second-line treatments or after their discontinuation and require appropriate clinical decisions. Lymphopenia is a result of the mechanism of action of many drugs used to treat MS. However, persistent lymphopenia and cell-specific lymphopenia could result in disease exacerbation, secondary autoimmunity, or the emergence of opportunistic infections. Clinicians treating patients with MS should be aware of the multiple faces of MS under novel, efficient treatment modalities and understand the intricate brain-immune cell interactions in the context of an altered immune system. MS relapses and disease progression still occur despite the current treatment modalities and are mediated either by failure to control effector mechanisms inherent to MS pathophysiology or by new drug-related mechanisms. The multiple faces of MS due to the highly adapted immune system of patients impose the need for appropriate switching therapies that safeguard disease remission and further clinical improvement.
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Affiliation(s)
- Aigli G Vakrakou
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece; Department of Neuropathology, University of Göttingen Medical Center, Göttingen, Germany.
| | - Maria-Evgenia Brinia
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Anastasia Alexaki
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelos Koumasopoulos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Panos Stathopoulos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria-Eleftheria Evangelopoulos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Leonidas Stefanis
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Constantinos Kilidireas
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece; Department of Neurology, Henry Dunant Hospital Center, Athens, Greece
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Loaiza JD, Chvatal-Medina M, Hernandez JC, Rugeles MT. Integrase inhibitors: current protagonists in antiretroviral therapy. Immunotherapy 2023; 15:1477-1495. [PMID: 37822251 DOI: 10.2217/imt-2023-0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023] Open
Abstract
Since HIV was identified as the etiological agent of AIDS, there have been significant advances in antiretroviral therapy (ART) that has reduced morbidity/mortality. Still, the viral genome's high mutation rate, suboptimal ART regimens, incomplete adherence to therapy and poor control of the viral load generate variants resistant to multiple drugs. Licensing over 30 anti-HIV drugs worldwide, including integrase inhibitors, has marked a milestone since they are potent and well-tolerated drugs. In addition, they favor a faster recovery of CD4+ T cells. They also increase the diversity profile of the gut microbiota and reduce inflammatory markers. All of these highlight the importance of including them in different ART regimens.
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Affiliation(s)
- John D Loaiza
- Grupo Inmunovirología, Facultad de medicina, Universidad de Antioquia, Medellín, 050010, Colombia
| | - Mateo Chvatal-Medina
- Grupo Inmunovirología, Facultad de medicina, Universidad de Antioquia, Medellín, 050010, Colombia
| | - Juan C Hernandez
- Infettare, Facultad de medicina, Universidad Cooperativa de Colombia, Medellín, 050012, Colombia
| | - Maria T Rugeles
- Grupo Inmunovirología, Facultad de medicina, Universidad de Antioquia, Medellín, 050010, Colombia
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Boga C, Eliacik E, Yalcin C, Kocer NE, Durdag E, Gereklioglu C. Diagnostic clues in a stem cell transplant patient manifested with chronic central nervous system GVHD and IRIS. Transpl Immunol 2023; 81:101916. [PMID: 37567484 DOI: 10.1016/j.trim.2023.101916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 08/08/2023] [Indexed: 08/13/2023]
Abstract
Transplant physicians should be aware of the immune deviation-related clinical conditions as allogeneic hematopoietic stem cell transplantation is widely used for the treatment of patients with malignant and non-malignant disorders. Neurological manifestations and graft-versus-host disease (GVHD) may commonly develop in transplant recipients. However, overlapping clinical immunological conditions may lead to diagnostic challenges. Herein, we discussed the differential diagnosis of a patient with immune reconstitution inflammatory syndrome (IRIS) developing on the basis of chronic GVHD.
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Affiliation(s)
- Can Boga
- Adana Adult Bone Marrow Transplantation Center, Department of Hematology, Başkent University Faculty of Medicine, Ankara, Turkiye.
| | - Eylem Eliacik
- Adana Adult Bone Marrow Transplantation Center, Department of Hematology, Başkent University Faculty of Medicine, Ankara, Turkiye
| | - Cigdem Yalcin
- Department of Radiology, Başkent University Faculty of Medicine, Ankara, Turkiye
| | - Nazım Emrah Kocer
- Department of Pathology, Başkent University Faculty of Medicine, Ankara, Turkiye
| | - Emre Durdag
- Department of Neurosurgery, Baskent University Faculty of Medicine, Ankara, Turkiye
| | - Cigdem Gereklioglu
- Department of Family Medicine, Başkent University Faculty of Medicine, Ankara, Turkiye
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7
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Min-ChunYeh, Chuang HC, Weng SF, Hsu CH, Huang CL, Lin YP, Lin YY, Hsieh YS. Newly diagnosed type 1 diabetes mellitus in a human immunodeficiency virus-infected patient with antiretroviral therapy-induced immune reconstitution inflammatory syndrome: a case report. BMC Infect Dis 2023; 23:619. [PMID: 37730544 PMCID: PMC10512543 DOI: 10.1186/s12879-023-08605-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 09/12/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND Diabetes that develops in human immunodeficiency virus (HIV)-infected patients who receive antiretroviral therapy (ART) is usually type 2 diabetes mellitus (T2DM); however, autoimmune diabetes, such as type 1 diabetes mellitus (T1DM) can also develop in this population. After treatment with ART, patients might experience clinical deterioration following an increase in the CD4 cell count, which is termed immune reconstitution inflammatory syndrome (IRIS). Here, we describe an HIV-infected patient on ART who developed T1DMat due to IRIS, highlighting the clinical complexity in diagnosis and treatment. CASE PRESENTATION A 36-year-old man infected with HIV had a nadir CD4 cell count of 15.53/μL before medication, which increased to 429.09/μL after 9 months of regular ART. The fasting serum glucose at 9 months was between 96 mg/dL and 117 mg/dL. After 11 months of ART, the patient was admitted to hospital for diabetic ketoacidosis (DKA) and Graves' disease (GD). Noninsulin antidiabetics (NIADs) were prescribed following the resolution of DKA. However, poor glycemic control was noted despite well-titrated NIADs. Further investigation demonstrated poor pancreatic beta cell function and elevated anti-glutamic acid decarboxylase (anti-GAD) and anti-tyrosine phosphatase-like insulinoma antigen 2 (anti-IA2) titers. According to the results, he was diagnosed with T1DM and received multiple daily injections(MDI) of insulin. The regimen of MDI was insulin degludec as basal insulin and insulin aspart as prandial insulin. After MDI therapy, his glycemic control was improved. CONCLUSION In this case, T1DM was ascribed to IRIS. Although this phenomenon has been demonstrated in previous case reports, further study is necessary to realize the mechanism of this association. Therefore, we emphasize that when HIV-infected patients on ART experience an unstable blood glucose level and abnormal thyroid function, physicians should consider T1DM and GD associated with ART-induced IRIS to reduce the subsequent complications and more serious endocrine dysfunction.
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Affiliation(s)
- Min-ChunYeh
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Medical University Hospital, Taipei City, Taiwan
| | - Han-Chuan Chuang
- Division of Infection Diseases, Department of Internal Medicine, Taipei Medical University Hospital, Taipei City, Taiwan
| | - Shuen-Fu Weng
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Medical University Hospital, Taipei City, Taiwan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan
| | - Chung-Huei Hsu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Medical University Hospital, Taipei City, Taiwan
| | - Chen-Ling Huang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Medical University Hospital, Taipei City, Taiwan
| | - Yu-Pei Lin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Medical University Hospital, Taipei City, Taiwan
| | - Yan-Yu Lin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Medical University Hospital, Taipei City, Taiwan
| | - Yu-Shan Hsieh
- School of Nursing, National Taipei University of Nursing and Health Sciences, No. 365, Mingde Rd., Beitou Dist, Taipei City, 112303 Taiwan
- Department of Research, Taipei Medical University Hospital, Taipei City, 11031 Taiwan
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8
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Hernanz I, Alvear-Torres A, Serrano Del Castillo C, Sánchez-Pernaute O, Recuero S, Romero-Bueno F, Muñoz N, Carreño E. Non-infectious Uveitis as a Manifestation of the Immune Reconstitution Inflammatory Syndrome in Patients Infected by HIV. Ocul Immunol Inflamm 2022; 30:1599-1603. [PMID: 33908843 DOI: 10.1080/09273948.2021.1919310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To describe a retrospective review of HIV patients with noninfectious uveitis. Data collected included: demographics, anatomic classification and phenotypic diagnosis of the uveitis, systemic immune-mediated disorders (IMD), time from HIV diagnosis to uveitis, CD4 count, viral load, treatment and complications of treatment and time of follow-up. RESULTS Twenty patients (18 males) were included. The time lag between HIV diagnosis and the onset of uveitis was 9 ± 8.5 years. Mean CD4 count was 670 ± 294 cells/ml. Viral load was undetectable in 14 out of 18 cases. In 6 patients IMD was diagnosed prior to or concurring with the uveitis diagnosis. The use of immunosuppressive therapies was necessary in 6 patients (including biologics in 4 cases). The mean follow-up was 42.2 months. CONCLUSIONS noninfectious uveitis could be the first manifestation of IMD in patients with well-controlled HIV infection. Immunosuppression appeared to be a safe therapeutic option in our cohort of patients.
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Affiliation(s)
- Ines Hernanz
- Ophthalmology Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Andrea Alvear-Torres
- Rheumatology Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | | | | | - Sheila Recuero
- Rheumatology Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | | | - Nelida Muñoz
- Ophthalmology Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Ester Carreño
- Ophthalmology Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
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9
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Why Are We Still Talking about Ivermectin? Editorial Note on Stone et al. Changes in SpO2 on Room Air for 34 Severe COVID-19 Patients after Ivermectin-Based Combination Treatment. Biologics 2022. [DOI: 10.3390/biologics2030016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In this issue of Biologics, we publish an article describing a surprising clinical effect of the anti-helminthic drug ivermectin on patients with COVID-19 [...]
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10
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Fernandez OE, Gudipati S, Ko D, Boucher A, Brar I. Papillomatous Anogenital Lesions in a Patient With Human Immunodeficiency Virus. Clin Infect Dis 2022; 75:172-175. [PMID: 36008926 PMCID: PMC9403295 DOI: 10.1093/cid/ciab853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Omar E Fernandez
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Smitha Gudipati
- Department of Infectious Disease, Henry Ford Hospital, Detroit, Michigan, USA
| | - Dayoung Ko
- Department of Dermatology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Alison Boucher
- Department of Dermatology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Indira Brar
- Department of Infectious Disease, Henry Ford Hospital, Detroit, Michigan, USA
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11
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Biotypes of HIV-associated neurocognitive disorders based on viral and immune pathogenesis. Curr Opin Infect Dis 2022; 35:223-230. [PMID: 35665716 PMCID: PMC9179892 DOI: 10.1097/qco.0000000000000825] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW HIV-associated neurocognitive disorders (HAND) continues to be prevalent in people living with HIV despite antiretroviral therapy. However, understanding disease mechanisms and identifying therapeutic avenues has been challenging. One of the challenges is that HAND is a heterogeneous disease and that patients identified with similar impairments phenotypically may have very different underlying disease processes. As the NeuroAIDS field is re-evaluating the approaches used to identify patients with HIV-associated neurological impairments, we propose the subtyping of patients into biotypes based on viral and immune pathogenesis. RECENT FINDINGS Here we review the evidence supporting subtyping patients with HIV-associated neurological complications into four biotypes: macrophage-mediated HIV encephalitis, CNS viral escape, T-cell-mediated HIV encephalitis, and HIV protein-associated encephalopathy. SUMMARY Subtyping patients into subgroups based on biotypes has emerged as a useful approach for studying heterogeneous diseases. Understanding biotypes of HIV-associated neurocognitive impairments may therefore enable better understanding of disease mechanisms, allow for the development of prognostic and diagnostic markers, and could ultimately guide therapeutic decisions.
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12
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Han X, Liu H, Wang Y, Wang P, Wang X, Yi Y, Li X. A nomogram for predicting paradoxical immune reconstitution inflammatory syndrome associated with cryptococcal meningitis among HIV-infected individuals in China. AIDS Res Ther 2022; 19:20. [PMID: 35473805 PMCID: PMC9044738 DOI: 10.1186/s12981-022-00444-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 04/11/2022] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Cryptococcal meningitis (CM) associated immune reconstitution inflammatory syndrome (CM-IRIS) is the second most common complication in HIV-infected individuals with cryptococcal meningitis, with a reported mortality rate ranging from 8 to 30%. Given the devastating consequences of CM-IRIS related intracranial neuroinflammation and its challenging in diagnosis, we conducted a study to explore the risk factors and the occurrence of paradoxical CM-IRIS in HIV-infected patients, which is of great value for prevention and clinical management. METHODS We conducted a retrospective cohort study to identify the indicators associated with paradoxical CM-IRIS among 86 HIV-infected patients with CM using univariate and multivariate cox analysis. A nomogram was constructed using selected variables to evaluate the occurrence of paradoxical CM-IRIS at 6 months and 12 months after ART initiation. The discrimination and calibration of the nomogram were assessed by concordance index (C-index) and calibration plots. Decision curves analysis (DCA) were used to evaluate clinical effectiveness of the nomogram. Subsequently, to help clinicians recognize patients at high risk faster, patients were divided into high-risk and low-risk groups according to the best cutoff point identified by X-tile. RESULTS Of 86 AIDS patients with CM, 22.1% experienced paradoxical CM-IRIS at a median of 32 days after antiretroviral therapy (ART) initiation. The occurrence of paradoxical CM-IRIS was associated with age, ART initiation within 4 weeks of antifungal treatment, a four-fold increase in CD4 T cell counts, C-reactive protein levels, and hemoglobin levels independently. These five variables were further used to construct a predictive nomogram. The C-index (0.876) showed the favorable discriminative ability of the nomogram. The calibration plot revealed a high consistency between the predicted and actual observations. DCA showed that the nomogram was clinically useful. Risk stratification based on the total score of the nomogram showed well-differentiated in the high-risk and low-risk groups. Clinicians should pay attention to patients with total points high than 273. CONCLUSIONS We identified the predictive factors of paradoxical CM-IRIS and constructed a nomogram to evaluate the occurrence of paradoxical CM-IRIS in 6 months and 12 months. The nomogram represents satisfactory performance and might be applied clinically to the screening and management of high-risk patients.
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Affiliation(s)
- Xiaoxu Han
- Department of Integrated Traditional Chinese and Western Medicine, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, People's Republic of China
| | - Hui Liu
- Department of Integrated Traditional Chinese and Western Medicine, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, People's Republic of China
| | - Yuqi Wang
- Department of Integrated Traditional Chinese and Western Medicine, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, People's Republic of China
| | - Peng Wang
- Department of Integrated Traditional Chinese and Western Medicine, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, People's Republic of China
| | - Xin Wang
- Department of Integrated Traditional Chinese and Western Medicine, Peking University Ditan Teaching Hospital, Beijing, 100015, People's Republic of China
| | - Yunyun Yi
- Department of Integrated Traditional Chinese and Western Medicine, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, People's Republic of China
| | - Xin Li
- Department of Integrated Traditional Chinese and Western Medicine, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, People's Republic of China.
- Department of Integrated Traditional Chinese and Western Medicine, Peking University Ditan Teaching Hospital, Beijing, 100015, People's Republic of China.
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13
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Tucker M, Sheikh AM, Villanueva MS. Rapidly enlarging pulmonary mass due to immune reconstitution inflammatory syndrome (IRIS) in an immunocompetent host with pulmonary Cryptococcus neoformans. BMJ Case Rep 2022; 15:e247495. [PMID: 35351746 PMCID: PMC8966528 DOI: 10.1136/bcr-2021-247495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2022] [Indexed: 11/04/2022] Open
Abstract
An immunocompetent man presented with Cryptococcus neoformans disease manifesting as a large pulmonary mass (cryptococcoma). Despite an initial induction course of 4 weeks of liposomal amphotericin B (LAmB), followed by 8 weeks of fluconazole, the cryptococcoma enlarged in size. Ten days into a second course of induction therapy with LAmB and flucytosine, the cryptococcoma markedly increased in size with encroachment on critical vascular structures. Due to concern for immune reconstitution inflammatory syndrome (IRIS), prednisone was added with significant decrease in the size of the mass. To our knowledge, this is the first reported case of pulmonary cryptococcal-IRIS in an immunocompetent host.
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Affiliation(s)
- Mollie Tucker
- Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Abdul Majeed Sheikh
- Infectious Diseases, Charlotte Hungerford Hospital, Torrington, Connecticut, USA
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14
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Makhoul J, Uppal S, Siegel M. Double Trouble: Concomitant Unmasking and Paradoxical Immune Reconstitution Inflammatory Syndrome in a Patient with Newly Diagnosed HIV. IDCases 2022; 28:e01482. [PMID: 35392599 PMCID: PMC8980619 DOI: 10.1016/j.idcr.2022.e01482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/09/2022] [Accepted: 03/23/2022] [Indexed: 11/02/2022] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) is a complication encountered in patients with HIV due to immune function recovery following the initiation of antiretroviral therapy. IRIS can be divided into two forms: paradoxical (recurrence of clinical signs of a previously treated opportunistic infection) and unmasking (uncovering of a previously undiagnosed and asymptomatic infection). We present the rare case of a 48-year-old man diagnosed with AIDS after presenting with cryptococcal meningitis who, shortly after initiation of ART, developed both unmasking IRIS due to Mycobacterium avium complex (MAC), and subsequently paradoxical IRIS to his prior cryptococcal meningitis infection. To our knowledge, cases in the medical literature describing “double IRIS” remain scarce.
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15
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AIDS Related Kaposi's Sarcoma: A 20-Year Experience in a Clinic from the South-East of Romania. J Clin Med 2021; 10:jcm10225346. [PMID: 34830628 PMCID: PMC8620409 DOI: 10.3390/jcm10225346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/11/2021] [Accepted: 11/15/2021] [Indexed: 11/16/2022] Open
Abstract
Kaposi’s sarcoma (KS) was peculiarly described in the first notified cases of the acquired immunodeficiency syndrome as an opportunistic condition. However, the medical progress and the development of active antiretroviral therapy allowed the control of the HIV/AIDS epidemic, although the features of KS have changed throughout the past decades. The purpose of our study is to assess the epidemiological and clinical features of AIDS related KS in Romanian patients. A retrospective follow-up study was achieved in a single infectious diseases’ clinic from Galati—Romania, between 2001 and 2021. Referring to 290 new HIV diagnosed cases from our clinic retained in care, the prevalence of KS was 3.4%. The main characteristics of patients with KS are a median age of 33, a predominance of males, prevalent severe systemic forms of diseases, frequent association of past or concomitant tuberculosis, and context of immune reconstruction syndrome. The mortality rate was 70%. KS has occurred in patients with delayed HIV diagnoses and inadequate adherence to therapy. Early recognition of both infections, the close monitoring of latent or symptomatic tuberculosis, improving the antiretroviral adherence and raising the access to oncologic procedures in Romanian HIV patients could improve their prognosis related to KS.
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16
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Moodley K, Bill PLA, Patel VB. A Comparison of Clinical, Electro-Diagnostic, Laboratory, and Treatment Outcome Differences in a Cohort of HIV-Infected and HIV-Uninfected Patients With Myasthenia Gravis. Front Neurol 2021; 12:738813. [PMID: 34721269 PMCID: PMC8553930 DOI: 10.3389/fneur.2021.738813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 09/13/2021] [Indexed: 11/13/2022] Open
Abstract
There is limited literature comparing the clinical parameters and treatment outcomes in HIV-infected and HIV-uninfected myasthenia gravis (MG) patients. The aim of the study was to investigate the clinical differences and treatment outcomes in the two categories of patients, particularly the safe use of immunosuppressive therapy in immunocompromised patients. The study was a retrospective analysis of medical records of MG patients from the neuromuscular unit at Inkosi Albert Luthuli Central Hospital in Kwa-Zulu Natal between 2003 and 2019. One hundred and seventy-eight (178) patients fulfilled the clinical criteria for MG. Twenty-four (13.4%) were HIV-infected and 154 (86.5%) were HIV-uninfected. There were 116 (65%) females, median 45 years, (IQR 40–62), 90 (50.5%) black African, 66 (37%) Indian, 20 (11.2%) white, and 2 (1.1%) of mixed ancestry. In the HIV-infected cohort, 20 (87%) had generalized MG, 12 (50%) bulbar, and 14 (60.9%) respiratory onset MG, 12 (50%) presented with MG Foundation of America (MGFA) class five diseases at diagnosis, six (25%) presented with MG crisis during the 5-year follow-up. Thirteen (54%) of the HIV-infected group required rescue therapy using (plasma exchange or IV immunoglobulin) combined with pulse cyclophosphamide compared with 17 (11%) in the HIV-uninfected cohort, respectively. At 5 years, 8 (33%) of the HIV-infected group remained refractory to treatment compared with 10 (6.5%) HIV-uninfected cohort, respectively. No adverse events were documented in HIV-infected patients receiving combination rescue therapy (PLEX or IVIG combined with IV cyclophosphamide). In conclusion HIV-infected MG patients are more likely to require combination rescue therapy with PE/IVIG and IV cyclophosphamide compared with those who were HIV-uninfected. No side effects were documented in the HIV-infected group receiving the above therapy.
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Affiliation(s)
- Kaminie Moodley
- Department of Neurology, University of KwaZulu-Natal, Durban, South Africa
| | - Pierre L A Bill
- Department of Neurology, University of KwaZulu-Natal, Durban, South Africa
| | - Vinod B Patel
- Department of Neurology, University of KwaZulu-Natal, Durban, South Africa
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17
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Cheng Z, Lin P, Cheng N. HBV/HIV Coinfection: Impact on the Development and Clinical Treatment of Liver Diseases. Front Med (Lausanne) 2021; 8:713981. [PMID: 34676223 PMCID: PMC8524435 DOI: 10.3389/fmed.2021.713981] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/23/2021] [Indexed: 02/05/2023] Open
Abstract
Hepatitis B virus (HBV) infection is a common contributor to chronic hepatitis, liver cirrhosis, and hepatocellular carcinoma. Approximately 10% of people with human immunodeficiency virus (HIV) also have chronic HBV co-infection, owing to shared transmission routes. HIV/HBV coinfection accelerates the progression of chronic HBV to cirrhosis, end-stage liver disease, or hepatocellular carcinoma compared to chronic HBV mono-infection. HBV/HIV coinfection alters the natural history of hepatitis B and renders the antiviral treatment more complex. In this report, we conducted a critical review on the epidemiology, natural history, and pathogenesis of liver diseases related to HBV/HIV coinfection. We summarized the novel therapeutic options for these coinfected patients.
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Affiliation(s)
- Zhimeng Cheng
- Department of Bile Duct Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Panpan Lin
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Nansheng Cheng
- Department of Bile Duct Surgery, West China Hospital, Sichuan University, Chengdu, China
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18
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Ludgate S, Connolly SP, Fennell D, Muhamad MF, Welaratne I, Cotter A, McQuaid SE. Graves' disease associated with HIV disease and late immune reconstitution inflammatory syndrome following the initiation of antiretroviral therapy. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM210094. [PMID: 34612207 PMCID: PMC8558905 DOI: 10.1530/edm-21-0094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 09/14/2021] [Indexed: 11/08/2022] Open
Abstract
SUMMARY Both human immunodeficiency virus (HIV) and antiretroviral therapy (ART) are associated with endocrine dysfunction (1). The term 'immune reconstitution inflammatory syndrome' (IRIS) describes an array of inflammatory conditions that occur during the return of cell-mediated immunity following ART. Graves' disease (GD) occurs rarely as an IRIS following ART. In this study, we describe the case of a 40-year-old Brazilian female who was diagnosed with HIV following admission with cryptococcal meningitis and salmonellosis. At this time, she was also diagnosed with adrenal insufficiency. Her CD4 count at diagnosis was 17 cells/µL which rose to 256 cells/µL over the first 3 months of ART. Her HIV viral load, however, consistently remained detectable. When viral suppression was finally achieved 21 months post diagnosis, an incremental CD4 count of 407 cells/µL over the following 6 months ensued. Subsequently, she was diagnosed with a late IRIS to cryptococcus 32 months following initial ART treatment, which manifested as non-resolving lymphadenitis and resolved with high-dose steroids. Following the initiation of ART for 45 months, she developed symptomatic Graves' hyperthyroidism. At this time, her CD4 count had risen to 941 cells/µL. She has been rendered euthyroid on carbimazole. This case serves to remind us that GD can occur as an IRIS post ART and typically has a delayed presentation. LEARNING POINTS Endocrinologists should be aware of the endocrine manifestations of HIV disease, in particular, thyroid pathology. Endocrinologists should be aware that IRIS can occur following the initiation of ART. Thyroid dysfunction can occur post ART of which Graves' disease (GD) is the most common thyroid manifestation. GD as a manifestation of ART-induced IRIS can have a delayed presentation. Infectious disease physicians should be aware of endocrine manifestations associated with HIV and ART.
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Affiliation(s)
- S Ludgate
- Department of Diabetes and Endocrinology, Dublin, Ireland
| | - S P Connolly
- Department of Infectious Diseases, Dublin, Ireland
| | - D Fennell
- Department of Diabetes and Endocrinology, Dublin, Ireland
| | - M F Muhamad
- Department of Diabetes and Endocrinology, Dublin, Ireland
| | - I Welaratne
- Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - A Cotter
- Department of Infectious Diseases, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - S E McQuaid
- Department of Diabetes and Endocrinology, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
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19
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Arakawa N, Eguchi K, Nakamura Y, Tsukahara Y, Koushima Y, Matsushima H. Immune Reconstitution Inflammatory Syndrome-like Condition Associated with Pneumocystis jirovecii Pneumonia During Folinic Acid Treatment in a Rheumatoid Arthritis Patient. Intern Med 2021; 60:3143-3147. [PMID: 33840694 PMCID: PMC8545637 DOI: 10.2169/internalmedicine.6577-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
A 94-year-old woman with rheumatoid arthritis who had been treated with low-dose methotrexate was referred to our hospital because of a 3-day history of a fever and pancytopenia. With a diagnosis of febrile neutropenia of unknown origin, empirical antibiotic treatment and folinic acid therapy were initiated. Despite a recovery from pancytopenia, the high fever remained, and dyspnea developed. She was clinically diagnosed with Pneumocystis jirovecii pneumonia (PCP) and successfully treated with trimethoprim/sulfamethoxazole and adjunctive corticosteroid therapy. Folinic acid treatment effectively brought about rapid immune recovery but might have led to a clinical manifestation of PCP resembling immune reconstruction inflammatory syndrome.
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Affiliation(s)
- Naoki Arakawa
- Department of General Internal Medicine, Saitama Red Cross Hospital, Japan
| | - Kazuo Eguchi
- Department of General Internal Medicine, Saitama Red Cross Hospital, Japan
| | - Yuki Nakamura
- Department of General Internal Medicine, Saitama Red Cross Hospital, Japan
| | - Yuta Tsukahara
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Japan
| | - Youhei Koushima
- Hepatobiliary Pancreatic Department, Saitama Red Cross Hospital, Japan
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20
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Derungs T, Leo F, Loddenkemper C, Schneider T. Treatment of disseminated nocardiosis: a host-pathogen approach with adjuvant interferon gamma. THE LANCET. INFECTIOUS DISEASES 2021; 21:e334-e340. [PMID: 34425068 DOI: 10.1016/s1473-3099(20)30920-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/03/2020] [Accepted: 11/16/2020] [Indexed: 12/19/2022]
Abstract
Disseminated nocardiosis is a rare, life-threatening disease. Particularly at risk are immunocompromised patients, highlighting the crucial role of host factors. Conventional intensive antibiotic treatment has improved survival rates, but the overall prognosis of patients with disseminated nocardiosis remains unsatisfactory. In this Grand Round, we present a case of severe nocardiosis that did not respond to standard therapy. The patient's condition deteriorated when antibiotic therapy was given alone and improved substantially only after coadministration of interferon gamma. We review the literature relevant to adjuvant interferon gamma therapy of nocardiosis and discuss its potential harms and benefits. Overall, we consider such treatment as beneficial and low risk if the patient is followed-up closely. We conclude that clinicians should consider this regimen in refractory cases of severe Nocardia infection.
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Affiliation(s)
- Thomas Derungs
- Department of Gastroenterology, Infectious Disease and Rheumatology, Charité Universitätsmedizin Berlin, Germany; Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.
| | - Fabian Leo
- Department of Gastroenterology, Infectious Disease and Rheumatology, Charité Universitätsmedizin Berlin, Germany; Department of Respiratory Medicine, Evangelische Lungenklinik, Berlin, Germany
| | | | - Thomas Schneider
- Department of Gastroenterology, Infectious Disease and Rheumatology, Charité Universitätsmedizin Berlin, Germany
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21
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Pei L, Fukutani KF, Tibúrcio R, Rupert A, Dahlstrom EW, Galindo F, Laidlaw E, Lisco A, Manion M, Andrade BB, Sereti I. Plasma Metabolomics Reveals Dysregulated Metabolic Signatures in HIV-Associated Immune Reconstitution Inflammatory Syndrome. Front Immunol 2021; 12:693074. [PMID: 34211479 PMCID: PMC8239348 DOI: 10.3389/fimmu.2021.693074] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 05/27/2021] [Indexed: 12/17/2022] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) is an inflammatory complication associated with an underlying opportunistic infection that can be observed in HIV-infected individuals shortly after the initiation of antiretroviral therapy, despite successful suppression of HIV viral load and CD4+ T cell recovery. Better understanding of IRIS pathogenesis would allow for targeted prevention and therapeutic approaches. In this study, we sought to evaluate the metabolic perturbations in IRIS across longitudinal time points using an unbiased plasma metabolomics approach as well as integrated analyses to include plasma inflammatory biomarker profile and whole blood transcriptome. We found that many lipid and amino acid metabolites differentiated IRIS from non-IRIS conditions prior to antiretroviral therapy and during the IRIS event, implicating the association between oxidative stress, tryptophan pathway, and lipid mediated signaling and the development of IRIS. Lipid and amino acid metabolic pathways also significantly correlated with inflammatory biomarkers such as IL-12p70 and IL-8 at the IRIS event, indicating the role of cellular metabolism on cell type specific immune activation during the IRIS episode and in turn the impact of immune activation on cellular metabolism. In conclusion, we defined the metabolic profile of IRIS and revealed that perturbations in metabolism may predispose HIV-infected individuals to IRIS development and contribute to the inflammatory manifestations during the IRIS event. Furthermore, our findings expanded our current understanding IRIS pathogenesis and highlighted the significance of lipid and amino acid metabolism in inflammatory complications.
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Affiliation(s)
- Luxin Pei
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, United States.,Department of Biology, Johns Hopkins University, Baltimore, MD, United States
| | - Kiyoshi F Fukutani
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil.,Laboratory of Inflammation and Biomarkers, Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador, Brazil.,Curso de Medicina, Centro Universitário Faculdade de Tecnologia e Ciências (UniFTC), Salvador, Brazil
| | - Rafael Tibúrcio
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil.,Laboratory of Inflammation and Biomarkers, Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador, Brazil.,Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil
| | - Adam Rupert
- Leidos Biomedical Research Inc., Frederick National Laboratory for Cancer Research, Frederick, MD, United States
| | - Eric W Dahlstrom
- Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Hamilton, MT, United States
| | - Frances Galindo
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, United States
| | - Elizabeth Laidlaw
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, United States
| | - Andrea Lisco
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, United States
| | - Maura Manion
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, United States
| | - Bruno B Andrade
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil.,Laboratory of Inflammation and Biomarkers, Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador, Brazil.,Curso de Medicina, Centro Universitário Faculdade de Tecnologia e Ciências (UniFTC), Salvador, Brazil.,Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil.,Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Irini Sereti
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, United States
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22
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Kim J, Nam HJ, Kang SJ, Jung SI, Hwang CH, Kim YS, Chang HH, Kim SW, Park KH. Integrase strand transfer inhibitor treatment does not increase the incidence of immune reconstitution inflammatory syndrome in HIV-infected Koreans. HIV Med 2021; 22:705-714. [PMID: 34046975 DOI: 10.1111/hiv.13117] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Immune reconstitution inflammatory syndrome (IRIS) is a major concern when starting antiretroviral therapy (ART) in patients with advanced HIV infection. The aim of this study was to determine the incidence and risk factors of IRIS in HIV-infected Koreans initiating ART, and whether integrase strand transfer inhibitor (INSTI) treatment increases the risk of IRIS. METHODS This retrospective analysis included adults living with HIV, seen at four university-affiliated hospitals in South Korea, who were naïve to ART and had a CD4 T-cell count < 200 cells/μL between January 2004 and May 2019. IRIS was determined through a medical record review within 6 months of ART initiation. Propensity score-matched case-control study between the non-INSTI and INSTI groups was performed. RESULTS The study included 501 patients; 192 were assigned to the INSTI group, who started ART based on INSTIs as the initial treatment. There were opportunistic infections (OIs) in 253 (50.5%) cases before ART initiation. The three most common OIs were Pneumocystis jirovecii pneumonia, candidiasis and tuberculosis (TB). We identified 47 cases of IRIS; TB-IRIS was the most common type. The incidence of IRIS within 6 months of ART initiation was 9.4%, and there were no significant differences in baseline characteristics and incidence of IRIS between the matched groups. The risk factors for IRIS were pre-ART CD4 T-cell count (< 30 cells/μL), higher pre-ART viral load (≥ 75 000 copies/mL), and TB-OI. CONCLUSIONS The incidence of IRIS was 9.4% in Korean HIV patients. The INSTI regimen was not related to IRIS occurrence.
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Affiliation(s)
- J Kim
- Department of Infectious Diseases, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - H-J Nam
- Department of Infectious Diseases, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - S-J Kang
- Department of Infectious Diseases, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - S-I Jung
- Department of Infectious Diseases, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - C H Hwang
- Biomedical Research Institute, Chonnam National University Hospital, Gwangju, Korea
| | - Y-S Kim
- Department of Internal Medicine, Chungnam National University Medical School, Deajeon, Korea
| | - H-H Chang
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - S-W Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - K-Hwa Park
- Department of Infectious Diseases, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
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23
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Miyoshi S, Oda N, Gion Y, Taki T, Mitani R, Takata I, Taniguchi A, Sato Y, Miyahara N. Exacerbation of pulmonary cryptococcosis associated with enhancement of Th2 response in the postpartum period. J Infect Chemother 2021; 27:1248-1250. [PMID: 33840597 DOI: 10.1016/j.jiac.2021.03.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 03/24/2021] [Accepted: 03/31/2021] [Indexed: 11/29/2022]
Abstract
Cryptococcosis is an invasive mycosis that has become increasingly prevalent in immunocompromised patients. Pregnant women are also one of the risk populations for cryptococcosis. Reversal of Th2 to Th1 response following resolution of immunosuppression during the postpartum period can lead to overt clinical manifestations of a previously silent infection, resembling an immune reconstitution inflammatory syndrome. Here, we report a case of a 30-year-old woman who had an exacerbation of pulmonary cryptococcosis in the postpartum period mimicking an immune reconstitution inflammatory syndrome. In the present case, chest computed tomography showed multiple small nodules on the day of the delivery; however, pulmonary cryptococcosis, which was subclinical during pregnancy, rapidly worsened to mass-like consolidation at one month after the delivery. Pathohistological examination of the lung specimen showed lung parenchyma infiltration with histiocytes and numerous lymphocytes without granulomatous formations, and a small number of yeast-like organisms consistent with Cryptococcus without capillary involvement. Immunohistochemical staining showed predominance of CD3+ cells and CD4+ cells over CD8+ cells. In addition, GATA3+ cells dominated over T-bet + cells. These data suggested exacerbation of pulmonary cryptococcosis associated with enhancement of Th2 response in the postpartum period.
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Affiliation(s)
- Shota Miyoshi
- Department of Internal Medicine, Fukuyama City Hospital, Fukuyama, Japan
| | - Naohiro Oda
- Department of Internal Medicine, Fukuyama City Hospital, Fukuyama, Japan.
| | - Yuka Gion
- Department of Medical Technology, Okayama University Graduate School of Health Sciences, Okayama, Japan
| | - Takahiro Taki
- Department of Internal Medicine, Fukuyama City Hospital, Fukuyama, Japan
| | - Reo Mitani
- Department of Internal Medicine, Fukuyama City Hospital, Fukuyama, Japan
| | - Ichiro Takata
- Department of Internal Medicine, Fukuyama City Hospital, Fukuyama, Japan
| | - Akihiko Taniguchi
- Department of Allergy and Respiratory Medicine, Okayama University Hospital, Okayama, Japan
| | - Yasuharu Sato
- Department of Medical Technology, Okayama University Graduate School of Health Sciences, Okayama, Japan
| | - Nobuaki Miyahara
- Department of Medical Technology, Okayama University Graduate School of Health Sciences, Okayama, Japan; Department of Allergy and Respiratory Medicine, Okayama University Hospital, Okayama, Japan
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24
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Archary M, Sartorius B, La Russa P, Sibaya T, Healy M, Bobat RA. Effect of the Timing of Antiretroviral Treatment Initiation on Outcomes in Children Living With Human Immunodeficiency Virus Admitted With Severe Acute Malnutrition. J Pediatric Infect Dis Soc 2021; 10:259-266. [PMID: 32469406 PMCID: PMC8023316 DOI: 10.1093/jpids/piaa054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 05/08/2020] [Indexed: 11/13/2022]
Abstract
BACKGROUND Delays in early infant diagnosis and antiretroviral treatment (ART) initiation in developing countries frequently result in malnutrition at initial presentation with associated higher mortality and delayed immune recovery. The optimal timing of ART initiation is yet to be established. METHODS Eighty-two children admitted with HIV and severe acute malnutrition (SAM) between July 2012 and December 2015 were enrolled. Patients were randomized to initiate ART within 14 days from admission (early arm) or delay ART initiation until nutritional recovery and >14 days after admission (delayed arm). All patients received a standardized treatment and feeding protocol and were followed to 48 weeks. RESULTS The mean age of the patients at baseline was 23.3 months (standard deviation [SD], 27.9; range, 1.6-129 months). The mean time from admission to ART initiation was 5.6 days (SD, 4.4) in the early arm and 23 days (SD, 5.8) in the delayed arm (P < .001). There was no significant difference in mortality (P = .62), virologic response (P = .53), and anthropometric response (P = .57) between the 2 groups at 48 weeks. However, the rates of change in CD4, viral load, weight for age z score, and height for age z score occurred earlier and favored the delayed arm at early time points but were not significant at 24 and 48 months. CONCLUSIONS Despite initial improved responses in the delayed arm, lack of difference in outcome at 48 weeks supports a pragmatic approach with earlier ART initiation in children living with HIV admitted with SAM.In this randomised controlled study of ART initiation in children admitted with HIV and severe acute malnutrition (SAM), despite initial improved responses in the delayed arm, lack of difference in outcome at 48 weeks supports a pragmatic approach with earlier ART initiation in children living with HIV admitted with SAM. CLINICAL TRIALS REGISTRATION PACTR 21609001751384.
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Affiliation(s)
- Moherndran Archary
- Paediatric Unit, King Edward VIII Hospital, Durban, South Africa
- Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Benn Sartorius
- School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Philip La Russa
- Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Thobekile Sibaya
- Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Micheal Healy
- Department of Medicine, Division of Infectious Diseases, Columbia University, New York, New York, USA
| | - Raziya A Bobat
- Paediatric Unit, King Edward VIII Hospital, Durban, South Africa
- Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
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25
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Lucas SB, Wong KT, Nightingale S, Miller RF. HIV-Associated CD8 Encephalitis: A UK Case Series and Review of Histopathologically Confirmed Cases. Front Neurol 2021; 12:628296. [PMID: 33868143 PMCID: PMC8047670 DOI: 10.3389/fneur.2021.628296] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 03/11/2021] [Indexed: 11/30/2022] Open
Abstract
HIV-associated CD8-encephalitis (HIV-CD8E) is a severe inflammatory disorder dominated by infiltration of the brain by CD8+ T-lymphocytes. It occurs in people with HIV, typically when the virus is apparently well-controlled by antiretroviral treatment (ART). HIV-CD8E presents with symptoms and signs related to marked cerebral inflammation and swelling, and can lead to coma and death unless treated promptly with corticosteroids. Risk events such as intercurrent infection, antiretroviral therapy interruption, immune reconstitution inflammatory syndrome (IRIS) after starting ART, and concomitant associations such as cerebrospinal fluid (CSF) HIV viral escape have been identified, but the pathogenesis of the disorder is not known. We present the largest case series of HIV-CD8E to date (n = 23), representing histopathologically confirmed cases in the UK. We also summarize the global literature representing all previously published cases with histopathological confirmation (n = 30). A new variant of HIV-CD8E is described, occurring on a background of HIV encephalitis (HIVE).Together these series, totalling 53 patients, provide new insights. CSF HIV viral escape was a frequent finding in HIV-CD8E occurring in 68% of those with CSF available and tested; ART interruption and IRIS were important, both occurring in 27%. Black ethnicity appeared to be a key risk factor; all but two UK cases were African, as were the majority of the previously published cases in which ethnicity was stated. We discuss potential pathogenic mechanisms, but there is no unifying explanation over all the HIV-CD8E scenarios.
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Affiliation(s)
- Sebastian B. Lucas
- Department of Cellular Pathology, Guys and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Kum T. Wong
- Department of Pathology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Sam Nightingale
- Department of Neurology, University of Cape Town, Cape Town, South Africa
| | - Robert F. Miller
- Centre for Clinical Research in Infection and Sexual Health, Institute for Global Health, University College London, London, United Kingdom
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, United Kingdom
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26
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Bansal S, Singhania N, Nukala CM, Singh AK, Al‐Rabadi L. Histoplasma stomatitis unveiled: Not all opportunistic infections get better after initiation of antiretroviral therapy. Clin Case Rep 2021; 9:1466-1468. [PMID: 33768869 PMCID: PMC7981768 DOI: 10.1002/ccr3.3799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 12/16/2020] [Accepted: 12/27/2020] [Indexed: 11/30/2022] Open
Abstract
Immune reconstitution inflammatory syndrome in AIDS patients can lead to an initial worsening of underlying diseases due to body's ability to mount a strong immune response after recovery of CD4 counts.
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Affiliation(s)
- Saurabh Bansal
- Department of Internal MedicineUniversity of Illinois College of Medicine at PeoriaPeoriaILUSA
| | - Namrata Singhania
- Department of Hospital MedicineMount Carmel East HospitalColumbusOHUSA
| | | | - Anil Kumar Singh
- Department of Internal MedicineGeisinger Community Medical CenterScrantonPAUSA
| | - Laith Al‐Rabadi
- Division of NephrologyUniversity of UtahSalt Lake City, UtahUSA
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27
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Castillejos-García I, Ramírez-Amador V, Gómez-Mejía E, Badial-Hernández F, Anaya-Saavedra G. Clinical manifestations and risk factors for oral immune reconstitution inflammatory syndrome in Mexico. Oral Dis 2020; 26 Suppl 1:153-157. [PMID: 32862543 DOI: 10.1111/odi.13402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The immune reconstitution inflammatory syndrome (IRIS) is a rare acute complication presenting in people living with HIV (PLWH) within the first 6 months of starting combined antiretroviral therapy (cART). While there is relevant information about its pathogenesis and clinical spectrum, IRIS-oral lesions (IRIS-OLs) have been scarcely described. Thus, to establish the incidence and clinical characteristics of IRIS-OLs, data from a cohort of 158 HIV individuals starting cART, followed for 6 months, were obtained retrospectively. IRIS-OLs developed in 11.4% of the individuals, in a median time of 87.5 days, with oral candidiasis being the most frequent manifestation detected in eight individuals (5.1%). The study emphasizes the importance of the correct diagnosis and management of these lesions.
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Affiliation(s)
- Itzel Castillejos-García
- Oral Pathology and Medicine Master, Universidad Autónoma Metropolitana-Xochimilco, Mexico City, Mexico
| | - Velia Ramírez-Amador
- Oral Pathology and Medicine Master, Universidad Autónoma Metropolitana-Xochimilco, Mexico City, Mexico
| | - Eduardo Gómez-Mejía
- Oral Pathology and Medicine Master, Universidad Autónoma Metropolitana-Xochimilco, Mexico City, Mexico
| | | | - Gabriela Anaya-Saavedra
- Oral Pathology and Medicine Master, Universidad Autónoma Metropolitana-Xochimilco, Mexico City, Mexico
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28
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NaserEddin A, Dinur-Schejter Y, Shadur B, Zaidman I, Even-Or E, Averbuch D, Shamriz O, Tal Y, Shaag A, Warnatz K, Elpeleg O, Stepensky P. Bacillus Calmette-Guerin (BCG) Vaccine-associated Complications in Immunodeficient Patients Following Stem Cell Transplantation. J Clin Immunol 2020; 41:147-162. [PMID: 33111199 PMCID: PMC7591244 DOI: 10.1007/s10875-020-00892-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/07/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE Bacillus Calmette-Guerin (BCG) is a live attenuated vaccine with the potential of causing severe iatrogenic complications in patients with primary immunodeficiency diseases (PID) before and after hematopoietic stem cell transplantation (HSCT). We aim to investigate risk factors of post-HSCT BCG-related complications in PID patients. METHODS A retrospective analysis of pediatric PID patients who had received the BCG vaccine and underwent HSCT at Hadassah-Hebrew University Medical Center, between 2007 and 2019. RESULTS We found 15/36 (41.67%) patients who developed post-HSCT BCG-related complications. The most significant risk factor for developing BCG-related complications was T cell deficiency (47.6% of the non-complicated vs 83.3% of the BCGitis and 100% of the BCGosis groups had T cell lymphopenia, p = 0.013). None of the chronic granulomatous patients developed BCG-related manifestation post-transplant. Among T cell-deficient patients, lower NK (127 vs 698 cells/μl, p = 0.04) cell counts and NK-SCID were risk factors for ongoing post-HSCT BCGosis, as was pretransplant disseminated BCGosis (33.3% of patients with BCGosis vs none of the non-BCGosis patients, p = 0.04). Immune reconstitution inflammatory syndrome (IRIS) was observed in 3/5 patients with Omenn syndrome. Prophylactic antimycobacterial treatment was not proven effective. CONCLUSION BCG vaccination can cause significant morbidity and mortality in the post-transplant T cell-deficient patient, especially in the presence of pre-transplant disease. Taking a detailed medical history prior to administering, the BCG vaccine is crucial for prevention of this complication.
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Affiliation(s)
- Adeeb NaserEddin
- Bone Marrow Transplantation Department, Hadassah-Hebrew University Medical Center, Jerusalem, Israel. .,Hadassah Medical Organization, POB 12000, Kiryat Hadassah, 91120, Jerusalem, Israel.
| | - Yael Dinur-Schejter
- Bone Marrow Transplantation Department, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.,Allergy & Clinical Immunology Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Bella Shadur
- Garvan Institute of Medical Research, Sydney, Australia.,Graduate Research School, University of New South Wales, Kensington, Australia
| | - Irina Zaidman
- Bone Marrow Transplantation Department, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ehud Even-Or
- Bone Marrow Transplantation Department, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Diana Averbuch
- Pediatric Infectious Diseases Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Oded Shamriz
- Allergy & Clinical Immunology Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Yuval Tal
- Allergy & Clinical Immunology Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Avraham Shaag
- Monique and Jacques Roboh Department of Genetic Research, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Klaus Warnatz
- Department for Rheumatology and Clinical Immunology and Center for Chronic Immunodeficiency (CCI), Medical Center, University of Freiburg, Faculty of Medicine, Freiburg im Breisgau, Germany.,Center for Chronic Immunodeficiency (CCI), Medical Center, University of Freiburg, Faculty of Medicine, Freiburg im Breisgau, Germany
| | - Orly Elpeleg
- Monique and Jacques Roboh Department of Genetic Research, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Polina Stepensky
- Bone Marrow Transplantation Department, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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29
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Salazar AS, Keller MR, Olsen MA, Nickel KB, George IA, Larson L, Powderly WG, Spec A. Potential missed opportunities for diagnosis of cryptococcosis and the association with mortality: A cohort study. EClinicalMedicine 2020; 27:100563. [PMID: 33205031 PMCID: PMC7648127 DOI: 10.1016/j.eclinm.2020.100563] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 09/04/2020] [Accepted: 09/11/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Cryptococcosis is one of the most common life-threatening opportunistic mycoses worldwide. Insidious presentation and slow onset of symptoms make it difficult to recognize, complicating the diagnostic process. Delays in diagnosis may lead to increased mortality. We aim to determine the frequency of missed opportunities for diagnosis of cryptococcosis and its effects on mortality. METHODS To estimate the proportion of individuals with a potentially missed diagnosis for cryptococcosis in hospitalized patients, we conducted a retrospective cohort study using the Healthcare Cost and Utilization Project State Inpatient Databases from 2005 to 2015 from eight states. All hospitalized adult patients diagnosed with cryptococcal infection or cryptococcal meningitis were included. Potentially missed diagnoses were defined as admissions coded for a procedure or diagnosis suggestive of cryptococcosis in the 90-days prior to the initial cryptococcosis admission. Generalized estimating equations models were used to evaluate the association between underlying comorbidities and potential missed diagnosis of cryptococcosis and 90-day all-cause in-hospital mortality. FINDINGS Of 5,354 patients with cryptococcosis, 2,445 (45·7%) were people living with HIV (PLWH). Among PLWH, 493/2,445 (20·2%) had a potentially missed diagnosis, of which 83/493 (16·8%) died while hospitalized compared with 265/1,952 (13·6%) of those without a potentially missed diagnosis (relative risk [RR] 1·04, 95% CI 0·99-1·09). Among HIV-negative patients, 977/2,909 (33·6%) had a potentially missed diagnosis, of which 236/977 (24·2%) died while hospitalized compared with 298/1,932 (15·4%) of those not missed (RR 1·12, 95% CI 1·07-1·16). INTERPRETATION Missed opportunities to diagnose cryptococcosis are common despite highly efficacious diagnostic tests and are associated with increased risk of 90-day mortality in HIV-negative patients. A high index of clinical suspicion is paramount to promptly diagnose, treat, and improve cryptococcosis-related mortality. FUNDING National Center for Advancing Translational Sciences, Washington University Institute of Clinical and Translational Sciences, and the Agency for Healthcare Research and Quality.
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Affiliation(s)
- Ana S Salazar
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine in St. Louis, 4523 Clayton Ave., Campus Box 8051, St Louis, MO 63110-0193, United Statess
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine in St. Louis, 660 S. Euclid Ave, Campus Box 8100, St. Louis, MO 63110-0193, USA
| | - Matthew R Keller
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine in St. Louis, 4523 Clayton Ave., Campus Box 8051, St Louis, MO 63110-0193, United Statess
| | - Margaret A Olsen
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine in St. Louis, 4523 Clayton Ave., Campus Box 8051, St Louis, MO 63110-0193, United Statess
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine in St. Louis, 660 S. Euclid Ave, Campus Box 8100, St. Louis, MO 63110-0193, USA
| | - Katelin B Nickel
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine in St. Louis, 4523 Clayton Ave., Campus Box 8051, St Louis, MO 63110-0193, United Statess
| | - Ige A George
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine in St. Louis, 4523 Clayton Ave., Campus Box 8051, St Louis, MO 63110-0193, United Statess
| | - Lindsey Larson
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine in St. Louis, 4523 Clayton Ave., Campus Box 8051, St Louis, MO 63110-0193, United Statess
| | - William G Powderly
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine in St. Louis, 4523 Clayton Ave., Campus Box 8051, St Louis, MO 63110-0193, United Statess
| | - Andrej Spec
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine in St. Louis, 4523 Clayton Ave., Campus Box 8051, St Louis, MO 63110-0193, United Statess
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30
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Lane KL, Moin T. AUTOIMMUNE DIABETES IN A PATIENT WITH HUMAN IMMUNODEFICIENCY VIRUS ON ANTI-RETROVIRAL THERAPY WITH LITERATURE REVIEW. AACE Clin Case Rep 2020; 6:e201-e206. [PMID: 32984521 DOI: 10.4158/accr-2019-0480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 04/08/2020] [Indexed: 12/28/2022] Open
Abstract
Objective Diabetes that develops in human immunodeficiency virus-infected individuals is typically classified as type 2 diabetes mellitus. Although less commonly reported, it has been shown that autoimmune diabetes can also develop in this population. Methods We present a case of a patient found to have autoimmune diabetes following initiation of anti-retroviral therapy. Results A 68-year-old, African American man with human immunodeficiency virus had a nadir CD4 count of 2 cells/μL, which improved with anti-retroviral therapy. He was subsequently diagnosed with type 2 diabetes mellitus but developed worsening glycemic control. Further investigation demonstrated an elevated glutamic acid decarboxylase antibody level >250 IU/mL and a declining C peptide level from 1.82 ng/mL to 0.56 ng/mL. He was ultimately diagnosed with autoimmune diabetes that was treated with insulin glargine and insulin aspart with improvement in his glycemic control. Conclusion Autoimmune diabetes in this case was attributed to immune reconstitution after anti-retroviral therapy led to recovery from a significantly low CD4 count. While this phenomenon has been described in previous case reports, our case was unique in that autoimmune diabetes affected an older African American man, a different demographic than previously reported. Although the true mechanism of this association remains unknown, the recognition of autoimmune diabetes is crucial as it greatly impacts diabetes management.
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Affiliation(s)
- Kyrstin L Lane
- Division of Endocrinology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, California.,VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Tannaz Moin
- Division of Endocrinology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, California.,Health Services Research and Development, Center for the Study of Healthcare Innovation, Implementation and Policy, Los Angeles, California
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31
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Che X, Jiang J, Qian Y, Li Q, Zhang Y, Wang Z. Case report-immune recovery posterior scleritis in a HIV positive patient. BMC Ophthalmol 2020; 20:262. [PMID: 32615955 PMCID: PMC7330949 DOI: 10.1186/s12886-020-01529-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 06/22/2020] [Indexed: 12/15/2022] Open
Abstract
Background Posterior scleritis is an uncommon vision-threatening disorder that is often recurrent and difficult to cure due to its complex etiology. In HIV patients, posterior scleritis may develop several months after significant rise in CD4+ T-lymphocyte, even after several years, which may be diagnosed as late-onset immune recovery scleritis. Case presentation Here we report a case of posterior scleritis in a HIV positive patient who presented with severe periocular pain and decreased vision in the left eye, with exudative retinal detachment and optic nerve involvement. Conclusions Early differential diagnosis of immune recovery posterior scleritis and intensive corticosteroids treatment, can prevent vision loss effectively in HIV patients.
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Affiliation(s)
- Xin Che
- Department of Ophthalmology, Huashan Hospital of Fudan University, No. 12, Middle Urumqi Road, Shanghai, 200040, China
| | - Jing Jiang
- Department of Ophthalmology, Huashan Hospital of Fudan University, No. 12, Middle Urumqi Road, Shanghai, 200040, China
| | - Yiwen Qian
- Department of Ophthalmology, Huashan Hospital of Fudan University, No. 12, Middle Urumqi Road, Shanghai, 200040, China
| | - Qingjian Li
- Department of Ophthalmology, Huashan Hospital of Fudan University, No. 12, Middle Urumqi Road, Shanghai, 200040, China
| | - Yu Zhang
- Department of Ophthalmology, Huashan Hospital of Fudan University, No. 12, Middle Urumqi Road, Shanghai, 200040, China
| | - Zhiliang Wang
- Department of Ophthalmology, Huashan Hospital of Fudan University, No. 12, Middle Urumqi Road, Shanghai, 200040, China.
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Fekrvand S, Yazdani R, Olbrich P, Gennery A, Rosenzweig SD, Condino-Neto A, Azizi G, Rafiemanesh H, Hassanpour G, Rezaei N, Abolhassani H, Aghamohammadi A. Primary Immunodeficiency Diseases and Bacillus Calmette-Guérin (BCG)-Vaccine-Derived Complications: A Systematic Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1371-1386. [PMID: 32006723 DOI: 10.1016/j.jaip.2020.01.038] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 01/13/2020] [Accepted: 01/14/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Bacillus Calmette-Guérin (BCG) vaccine is a live attenuated bacterial vaccine derived from Mycobacterium bovis, which is mostly administered to neonates in regions where tuberculosis is endemic. Adverse reactions after BCG vaccination are rare; however, immunocompromised individuals and in particular patients with primary immunodeficiencies (PIDs) are prone to develop vaccine-derived complications. OBJECTIVE To systematically review demographic, clinical, immunologic, and genetic data of PIDs that present with BCG vaccine complications. Moreover, we performed a meta-analysis aiming to determine the BCG-vaccine complications rate for patients with PID. METHODS We conducted electronic searches on Embase, Web of Science, PubMed, and Scopus (1966 to September 2018) introducing terms related to PIDs, BCG vaccination, and BCG vaccine complications. Studies with human subjects with confirmed PID, BCG vaccination history, and vaccine-associated complications (VACs) were included. RESULTS A total of 46 PIDs associated with BCG-VAC were identified. Severe combined immunodeficiency was the most common (466 cases) and also showed the highest BCG-related mortality. Most BCG infection cases in patients with PID were reported from Iran (n = 219 [18.8%]). The overall frequency of BCG-VAC in the included 1691 PID cases was 41.5% (95% CI, 29.9-53.2; I2 = 98.3%), based on the results of the random-effect method used in this meta-analysis. Patients with Mendelian susceptibility to mycobacterial diseases had the highest frequency of BCG-VACs with a pooled frequency of 90.6% (95% CI, 79.7-1.0; I2 = 81.1%). CONCLUSIONS Several PID entities are susceptible to BCG-VACs. Systemic neonatal PID screening programs may help to prevent a substantial amount of BCG vaccination complications.
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Affiliation(s)
- Saba Fekrvand
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Science, Tehran, Iran
| | - Reza Yazdani
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Science, Tehran, Iran.
| | - Peter Olbrich
- Sección de Infectología e Inmunopatología, Unidad de Pediatría, Hospital Virgen del Rocío/Instituto de Biomedicina de Sevilla, Seville, Spain
| | - Andrew Gennery
- Institute of Cellular Medicine, Newcastle University, and Paediatric Immunology and Haematopoietic Stem Cell Transplantation, Great North Children's Hospital, Newcastle upon Tyne, United Kingdom
| | - Sergio D Rosenzweig
- Immunology Service, Department of Laboratory Medicine, National Institutes Clinical Center, National Institutes of Health, Bethesda, Md
| | - Antonio Condino-Neto
- Department of Immunology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Gholamreza Azizi
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Hosein Rafiemanesh
- Student Research Committee, Department of Epidemiology, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Gholamreza Hassanpour
- Center for Research of Endemic Parasites of Iran, Tehran University of Medical Sciences, Tehran, Iran
| | - Nima Rezaei
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Science, Tehran, Iran; Network for Immunology in Infection, Malignancy, and Autoimmunity (NIIMA), Universal Scientific Education and Research Network, Tehran, Iran
| | - Hassan Abolhassani
- Division of Clinical Immunology, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, Sweden; Research Center for Primary Immunodeficiencies, Iran University of Medical Sciences, Tehran, Iran
| | - Asghar Aghamohammadi
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Science, Tehran, Iran.
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Stingone C, Sarmati L, Andreoni M. The Clinical Spectrum of Human Immunodeficiency Virus Infection. Sex Transm Infect 2020. [DOI: 10.1007/978-3-030-02200-6_15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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Hemophagocytic Lymphohistiocytosis in an AIDS Patient with Kaposi Sarcoma: A Treatment Dilemma. Case Rep Hematol 2019; 2019:7634760. [PMID: 31687230 PMCID: PMC6800897 DOI: 10.1155/2019/7634760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 09/16/2019] [Indexed: 11/17/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a result of an abnormal activation of immune cells (T lymphocytes, natural killer cells, and macrophages) resulting in cytokine overproduction and immune destruction of cells, eventually resulting in multiorgan failure. Genetic causes are responsible for primary hemophagocytosis, but malignancies, infections, and autoimmunity underlie most of the secondary cases. We present an unusual case of a patient with AIDS and disseminated Kaposi sarcoma who was commenced on highly active antiretroviral therapy (HAART) but developed HLH secondary to immune reconstitution inflammatory syndrome (IRIS). We report this case to highlight the difficulty in managing this patient given the complex interplay of immunosuppression due to AIDS, immune reconstitution following initiation of HAART, and immune overdrive manifesting as HLH.
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Kirincich J, Basic-Jukic N, Radic J, Lovric-Kujundzic S, Kastelan Z. A Kidney Transplant Recipient With Fulminant Progressive Multifocal Leukoencephalopathy-Immune Reconstitution Inflammatory Syndrome: A Rare Clinical Outcome and Review of the Literature. EXP CLIN TRANSPLANT 2019; 18:242-246. [PMID: 31580233 DOI: 10.6002/ect.2018.0227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Progressive multifocal leukoencephalopathy is a devastating disease affecting the central nervous system that may be seen in immunocompromised patients. We present a case of a kidney transplant recipient who received tacrolimus, mycophenolic acid, and prednisone and who developed motor deficits, altered cognition, and speech abnormalities, which culminated in a coma. The diagnosis was made by detecting John Cunningham polyomavirus DNA with polymerase chain reaction and observing characteristic findings on magnetic resonance imaging. Soon after immunosuppressive therapy was withdrawn, the patient's clinical status deteriorated due to immune reconstitution inflammatory syndrome, and prednisone was administered. Unfortunately, the patient died about 9 months after onset of symptoms. This case serves to illustrate the fulminant progression of progressive multifocal leukoencephalopathy and the possible complications that may arise when treating it.
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Affiliation(s)
- Jason Kirincich
- >From the Department of Nephrology, Arterial Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
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Kwon HY, Han YJ, Im JH, Baek JH, Lee JS. Two cases of immune reconstitution inflammatory syndrome in HIV patients treated with thalidomide. Int J STD AIDS 2019; 30:1131-1135. [PMID: 31533530 DOI: 10.1177/0956462419847297] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Immune reconstitution inflammatory syndrome (IRIS) is a clinical manifestation that accompanies paradoxical deterioration of symptoms in human immunodeficiency virus (HIV)-infected patients after commencement of antiretroviral treatment. This disease is caused by immune dysregulation, resulting in a cytokine storm and limited effector T-cell function. IRIS treatment involves supportive care and corticosteroid therapy to regulate the immune response. However, prolonged steroid therapy may increase the risk of opportunistic infections. Previous studies have highlighted the use of thalidomide to shorten the duration of steroid use. Herein, we report two cases of IRIS in HIV-infected patients whose symptoms were successfully controlled with thalidomide therapy. Both patients had opportunistic infections involving the central nervous system; one patient had cryptococcal meningitis and the other had progressive multifocal leukoencephalopathy.
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Affiliation(s)
- Hea Yoon Kwon
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Ye Jeong Han
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Jae Hyoung Im
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Ji Hyeon Baek
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Jin-Soo Lee
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
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37
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Bindra BS, Garcia de de Jesus K, Cisneros O, Jorge VM, Kaur H. Hemophagocytic Lymphohistiocytosis: Management and Special Consideration in Human Immunodeficiency Virus Positive Patients with Immune Reconstitution Syndrome. Cureus 2019; 11:e5402. [PMID: 31620325 PMCID: PMC6793597 DOI: 10.7759/cureus.5402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The human body is capable of reacting to multiple aggressors by developing an inflammatory response with the secretion of inflammatory cytokines. The worrisome clinical manifestations occur when this inflammatory response is disproportionate. Hemophagocytic lymphohistiocytosis (HLH) is a rare and severe condition characterized by an overwhelming inflammatory response that may result in end-organ damage and might be fatal. Correspondingly, immune reconstitution inflammatory syndrome (IRIS) is another well-known disorder, seen commonly in human immunodeficiency virus (HIV)-infected patients after the commencement of highly active antiretroviral therapy (HAART). Both entities share a similar clinical presentation and a dismal prognosis. Due to widespread clinical manifestations and laboratory abnormalities, diagnosis is often missed at the time of presentation. There is little consensus on the treatment of secondary HLH, which is usually handled on a case-by-case basis. Rapid curbing of the widespread inflammatory response is the main goal of treatment. To the best of our knowledge, there is scarce literature available on the coexistence of HLH and IRIS; therefore, medical management in the co-occurrence of these two conditions needs to be further investigated.
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Affiliation(s)
- Bikramjit S Bindra
- Internal Medicine, Government Medical College and Hospital, Chandigarh, IND
| | | | - Oscar Cisneros
- Internal Medicine, St. Barnabas Hospital Health System / Albert Einstein College of Medicine, Bronx, USA
| | - Vinicius M Jorge
- Hematology and Medical Oncology, Albert Einstein Medical Center, Philadelphia, USA
| | - Harpreet Kaur
- Internal Medicine, Albert Einstein Medical Center, Philadelphia, USA
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38
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Yu WY, Lu PX, Assadi M, Huang XL, Skrahin A, Rosenthal A, Gabrielian A, Tartakovsky M, Wáng YXJ. Updates on 18F-FDG-PET/CT as a clinical tool for tuberculosis evaluation and therapeutic monitoring. Quant Imaging Med Surg 2019; 9:1132-1146. [PMID: 31367568 DOI: 10.21037/qims.2019.05.24] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Tuberculosis (TB) is currently the world's leading cause of infectious mortality. The complex immune response of the human body to Mycobacterium tuberculosis (M.tb) results in a wide array of clinical manifestations, thus the clinical and radiological diagnosis can be challenging. 18F-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) scan with/without computed tomography (CT) component images the whole body and provides a metabolic map of the infection, enabling clinicians to assess the disease burden. 18F-FDG-PET/CT scan is particularly useful in detecting the disease in previously unknown sites, and allows the most appropriate site of biopsy to be selected. 18F-FDG-PET/CT is also very valuable in assessing early disease response to therapy, and plays an important role in cases where conventional microbiological methods are unavailable and for monitoring response to therapy in cases of multidrug-resistant TB or extrapulmonary TB. 18F-FDG-PET/CT cannot reliably differentiate active TB lesion from malignant lesions and false positives can also be due to other infective or inflammatory conditions. 18F-FDG PET is also unable to distinguish tuberculous lymphadenitis from metastatic lymph node involvement. The lack of specificity is a limitation for 18F-FDG-PET/CT in TB management.
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Affiliation(s)
- Wei-Ye Yu
- Shenzhen Center for Chronic Disease Control, Shenzhen 518055, China
| | - Pu-Xuan Lu
- Shenzhen Center for Chronic Disease Control, Shenzhen 518055, China
| | - Majid Assadi
- The Persian Gulf Nuclear Medicine Research Center, Bushehr University Of Medical Sciences, Bushehr, Iran
| | - Xi-Ling Huang
- Department of Imaging and Interventional Radiology, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
| | - Aliaksandr Skrahin
- Republican Scientific and Practical Centre of Pulmonology and Tuberculosis, Ministry of Health, Minsk, Belarus.,Belarus State Medical University, Minsk, Belarus
| | - Alex Rosenthal
- Office of Cyber Infrastructure and Computational Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland, USA
| | - Andrei Gabrielian
- Office of Cyber Infrastructure and Computational Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland, USA
| | - Michael Tartakovsky
- Office of Cyber Infrastructure and Computational Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland, USA
| | - Yì Xiáng J Wáng
- Department of Imaging and Interventional Radiology, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
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de Souza Campos Fernandes RC, Louvain de Souza T, da Silva Barcellos T, Medina-Acosta E. An Exclusively Skewed Distribution of Pediatric Immune Reconstitution Inflammatory Syndrome Toward the Female Sex Is Associated With Advanced Acquired Immune Deficiency Syndrome. Front Pediatr 2019; 7:293. [PMID: 31355171 PMCID: PMC6635464 DOI: 10.3389/fped.2019.00293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 06/28/2019] [Indexed: 11/29/2022] Open
Abstract
In human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS) patients with very low CD4 cell counts, there is a temporal relationship between administration of antiretroviral therapy (ART) and an increased inflammatory response state known as the immune reconstitution inflammatory syndrome (IRIS). The predominant clinical presentation of IRIS is an infectious disease that can be life-threatening. IRIS-related infectious events are distributed similarly between adult males and females, albeit a few studies have shown a skewing toward the male sex in pediatric IRIS. Here, we assessed sex-specific differences in the causes and extent of IRIS infectious events in HIV-infected pediatric patients on ART. We carried out a prospective clinical analysis (from 2000 to 2018) of IRIS-related infectious events after ART in a cohort of 82 Brazilian children and adolescents infected with HIV-1 through mother-to-child transmission as well as a comprehensive cross-referencing with public records on IRIS-related infectious causes in pediatric HIV/AIDS. Twelve events fulfilling the criteria of IRIS occurred exclusively in 11 females in our cohort. The median age at IRIS events was 3.6 years. The infectious causes included Mycobacterium bovis, varicella-zoster virus, molluscum contagiosum virus, human papillomavirus, cytomegalovirus, and Mycobacterium tuberculosis. In one female, there was regional bacillus Calmette-Guérin dissemination and cytomegalovirus esophagitis. There was complete health recovery after 10 IRIS events without the use of corticosteroids or ART interruption. One case of IRIS-associated miliary tuberculosis was fatal. The biological female sex was a significant risk factor for IRIS events (odds ratio: 23.67; 95% confidence interval 95%: 1.341-417.7; P = 0.0016 and P < 0.01 by the multivariable analysis). We observed an effect of the advanced HIV/AIDS variable in IRIS females as compared with non-IRIS females (mean CD4+ T cell percentage 13.36 vs. 18.63%; P = 0.0489 and P < 0.05 by the multivariable analysis), underpinning the exclusively skewed distribution toward the female sex of this cohort. Moreover, the IRIS females in our cohort had higher mean CD4+ T cell percentages before (13.36%) and after IRIS (26.56%) than those of the IRIS females (before IRIS, 4.978%; after IRIS, 13.81%) in previous studies conducted worldwide. The exclusively skewed distribution of pediatric IRIS toward the female sex in the cohort was not linked to preferential X-chromosome inactivation rates. We concluded that the exclusively skewed distribution of pediatric IRIS toward females is associated with more advanced AIDS.
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Affiliation(s)
- Regina Célia de Souza Campos Fernandes
- Faculty of Medicine of Campos, Campos dos Goytacazes, Brazil.,Municipal Program for the Surveillance of Sexually Transmitted Diseases and Acquired Immunodeficiency Syndrome of Campos dos Goytacazes, Campos dos Goytacazes, Brazil.,Molecular Identification and Diagnosis Unit, Laboratory of Biotechnology, Center for Biosciences and Biotechnology, Universidade Estadual do Norte Fluminense Darcy Ribeiro, Campos dos Goytacazes, Brazil
| | - Thaís Louvain de Souza
- Faculty of Medicine of Campos, Campos dos Goytacazes, Brazil.,Molecular Identification and Diagnosis Unit, Laboratory of Biotechnology, Center for Biosciences and Biotechnology, Universidade Estadual do Norte Fluminense Darcy Ribeiro, Campos dos Goytacazes, Brazil
| | | | - Enrique Medina-Acosta
- Molecular Identification and Diagnosis Unit, Laboratory of Biotechnology, Center for Biosciences and Biotechnology, Universidade Estadual do Norte Fluminense Darcy Ribeiro, Campos dos Goytacazes, Brazil
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40
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Rowley MW, Patel A, Zhou W, Wong M, Seetharam AB. Immune Reconstitution Syndrome with Initiation of Treatment of HBV/HIV Co-infection: Activity Flare associated with E antigen Seroconversion. Ann Hepatol 2019; 18:220-224. [PMID: 31113594 DOI: 10.5604/01.3001.0012.7918] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 07/17/2017] [Indexed: 02/04/2023]
Abstract
Immune reconstitution syndrome is a recognized complication with initiation of highly active antiretroviral therapy for acquired immune deficiency syndrome patients co-infected with hepatitis B. Hepatitis B flares are seen in 20%-25% of patients after initiation of highly active antiretroviral therapy, an estimated 1%-5% of whom develop clinical hepatitis. We present a case of highly active antiretroviral therapy initiation for HIV that led to a flare of HBV activity despite antiviral therapy directed towards both. Liver biopsy and longitudinal serologic evaluation lend support to the hypothesis that the flare in activity was representative of IRIS. Importantly, we document eAg/eAb seroconversion with the IRIS phenomenon.
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Affiliation(s)
- Michael W Rowley
- Department of Internal Medicine, Banner University Medical Center Phoenix, Phoenix, AZ, USA; Transplant and Advanced Liver Disease Center, Banner University Medical Center Phoenix, Phoenix, AZ, USA.
| | - Amitkumar Patel
- Department of Gastroenterology, Banner University Medical Center Phoenix, Phoenix, AZ, USA; Transplant and Advanced Liver Disease Center, Banner University Medical Center Phoenix, Phoenix, AZ, USA
| | - Wendi Zhou
- Department of Pathology, Banner University Medical Center Phoenix, Phoenix, AZ, USA; University of Arizona College of Medicine Phoenix, Phoenix, AZ, USA
| | - Mark Wong
- Transplant and Advanced Liver Disease Center, Banner University Medical Center Phoenix, Phoenix, AZ, USA; University of Arizona College of Medicine Phoenix, Phoenix, AZ, USA
| | - Anil B Seetharam
- Transplant and Advanced Liver Disease Center, Banner University Medical Center Phoenix, Phoenix, AZ, USA; University of Arizona College of Medicine Phoenix, Phoenix, AZ, USA
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Rapid onset of hypercalcemia from high-grade lymphoma in the setting of HIV-related immune reconstitution inflammatory syndrome. Bone Rep 2018; 10:100194. [PMID: 30627599 PMCID: PMC6319307 DOI: 10.1016/j.bonr.2018.100194] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 11/21/2018] [Accepted: 12/27/2018] [Indexed: 12/15/2022] Open
Abstract
Hypercalcemia in HIV patients has been previously reported, but 1,25-(OH)2 vitamin D-mediated hypercalcemia, due to increased activity of extrarenal 1-alpha hydroxylase, is rarely described with HIV-related infections or malignancies. We describe a case of 1,25-(OH)2 vitamin D-mediated hypercalcemia in a patient presenting with progressive cognitive decline and weakness. Initial evaluation revealed a new diagnosis of HIV, for which he was started on antiretroviral therapy (ART). He was also noted to have mild asymptomatic hypocalcemia, likely from his acute illness and malnutrition, which was not further investigated at the time. While the patient's mental status initially improved with ART, he became progressively delirious and was found to be hypercalcemic approximately 4 weeks after the initiation of ART. Possible etiologies for hypercalcemia were vigorously evaluated, including granulomatous disease, infection, and malignancy, in the setting of suspected immune reconstitution inflammatory syndrome (IRIS), due to recent initiation of ART. Infectious workup was unrevealing, but computed tomography (CT) of the chest, abdomen, and pelvis revealed new extensive diffuse lymphadenopathy and hepatomegaly, not present on admission studies. Cytology and flow cytometry of a liver biopsy specimen revealed CD10 positive high-grade B-cell lymphoma. Chemotherapy was not pursued due to poor performance status. Over the next week, spontaneous tumor lysis developed, and the patient expired. Postmortem, his 1,25-(OH)2 vitamin D level returned as markedly elevated. Immunohistochemical staining of his liver biopsy tissue showed strong expression of CYP27B1. 1,25-(OH)2 vitamin D-mediated hypercalcemia is uncommon in a patient with newly diagnosed HIV and, in this case, was likely due to IRIS unmasking an underlying high-grade lymphoma and restoration of immune function (including T-cells and cytokine production). This case emphasizes the importance of including aggressive lymphomas, capable of progressing over days to weeks, in the evaluation of hypercalcemia in HIV patients at risk for developing IRIS and the rapid dynamic changes in mineral homeostasis that can occur with such an aggressive tumor in an immunocompromised host. 1,25‑(OH)2 vitamin D-mediated hypercalcemia is uncommon in patients with HIV. Lymphomas are associated with immune reconstitution inflammatory syndrome (IRIS). Consider lymphoma in the evaluation of hypercalcemia in HIV patients at risk for IRIS.
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Dellière S, Guery R, Candon S, Rammaert B, Aguilar C, Lanternier F, Chatenoud L, Lortholary O. Understanding Pathogenesis and Care Challenges of Immune Reconstitution Inflammatory Syndrome in Fungal Infections. J Fungi (Basel) 2018; 4:E139. [PMID: 30562960 PMCID: PMC6308948 DOI: 10.3390/jof4040139] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 12/14/2018] [Accepted: 12/15/2018] [Indexed: 12/16/2022] Open
Abstract
Immune deficiency of diverse etiology, including human immunodeficiency virus (HIV), antineoplastic agents, immunosuppressive agents used in solid organ recipients, immunomodulatory therapy, and other biologics, all promote invasive fungal infections. Subsequent voluntary or unintended immune recovery may induce an exaggerated inflammatory response defining immune reconstitution inflammatory syndrome (IRIS), which causes significant mortality and morbidity. Fungal-associated IRIS raises several diagnostic and management issues. Mostly studied with Cryptococcus, it has also been described with other major fungi implicated in human invasive fungal infections, such as Pneumocystis, Aspergillus, Candida, and Histoplasma. Furthermore, the understanding of IRIS pathogenesis remains in its infancy. This review summarizes current knowledge regarding the clinical characteristics of IRIS depending on fungal species and existing strategies to predict, prevent, and treat IRIS in this patient population, and tries to propose a common immunological background to fungal IRIS.
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Affiliation(s)
- Sarah Dellière
- Medical School, Paris-Descartes University, APHP, Necker-Enfants Malades Hospital, Infectious Disease Center Necker-Pasteur, IHU Imagine, 75015 Paris, France.
| | - Romain Guery
- Medical School, Paris-Descartes University, APHP, Necker-Enfants Malades Hospital, Infectious Disease Center Necker-Pasteur, IHU Imagine, 75015 Paris, France.
| | - Sophie Candon
- Medical School, Paris-Descartes University, INSERM U1151-CNRS UMR 8253APHP, Necker-Enfants Malades Hospital, APHP, Clinical Immunology, 75015 Paris, France.
| | - Blandine Rammaert
- Medical School, Poitiers University, Poitiers, France; Poitiers University Hospital, Infectious Disease Unit, Poitiers, France; INSERM U1070, 86022 Poitiers, France.
| | - Claire Aguilar
- Medical School, Paris-Descartes University, APHP, Necker-Enfants Malades Hospital, Infectious Disease Center Necker-Pasteur, IHU Imagine, 75015 Paris, France.
| | - Fanny Lanternier
- Medical School, Paris-Descartes University, APHP, Necker-Enfants Malades Hospital, Infectious Disease Center Necker-Pasteur, IHU Imagine, 75015 Paris, France.
- Pasteur Institute, Molecular Mycology Unit, National Reference Center for Invasive Fungal Disease and Antifungals, CNRS UMR 2000, 75015 Paris, France.
| | - Lucienne Chatenoud
- Medical School, Paris-Descartes University, INSERM U1151-CNRS UMR 8253APHP, Necker-Enfants Malades Hospital, APHP, Clinical Immunology, 75015 Paris, France.
| | - Olivier Lortholary
- Medical School, Paris-Descartes University, APHP, Necker-Enfants Malades Hospital, Infectious Disease Center Necker-Pasteur, IHU Imagine, 75015 Paris, France.
- Pasteur Institute, Molecular Mycology Unit, National Reference Center for Invasive Fungal Disease and Antifungals, CNRS UMR 2000, 75015 Paris, France.
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Abstract
OBJECTIVES Possible effects of HIV on thyroid function in the modern combination antiretroviral therapy (cART) era are largely unknown. We aimed to investigate the prevalence and associated risk factors of thyroid dysfunction in well treated people living with HIV (PLWH) and matched uninfected controls and to examine whether HIV is independently associated with thyroid dysfunction. DESIGN AND METHODS Thyroid-stimulating hormone (TSH), free thyroxine, total thyroxine, and free triiodothyronine were measured in 826 PLWH from the Copenhagen co-morbidity in HIV infection (COCOMO) Study and in 2503 matched uninfected controls, and medical treatment for hypothyroidism or hyperthyroidism was recorded. Multinomial logistic regression adjusting for known risk factor was used to examine the association between HIV and thyroid dysfunction and multivariate linear regression to study the association between HIV and serum TSH concentrations. RESULTS The PLWH were generally well treated, with 95% having undetectable viral replication. Among PLWH and controls 31 (3.8%) and 114 (4.6%) had hypothyroidism, and 7 (0.8%) and 21 (0.8%) had hyperthyroidism, respectively. In adjusted analyses, we found no significant associations between HIV and hypothyroidism OR 0.8 [95% confidence interval (CI) 0.6-1.3], P = 0.40 or between HIV and hyperthyroidism OR 1.1 (95% CI 0.5-2.5), P = 0.91. Furthermore, serum TSH concentration was unrelated to HIV status (P = 0.6). CONCLUSION There was no difference in the prevalence of hyperthyroidism or hypothyroidism in well treated PLWH compared with uninfected controls. HIV status was not associated with thyroid dysfunction or serum TSH concentration.
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Mirza FS, Luthra P, Chirch L. Endocrinological aspects of HIV infection. J Endocrinol Invest 2018; 41:881-899. [PMID: 29313284 DOI: 10.1007/s40618-017-0812-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 12/16/2017] [Indexed: 02/06/2023]
Abstract
PURPOSE Patients with human immunodeficiency virus (HIV) are living longer with effective antiretroviral therapies and are enjoying near normal life span. Therefore, they are encountering endocrine issues faced by the general population along with those specific to HIV infection. The purpose of this article is to review the common endocrine aspects of HIV infection, and the early detection and management strategies for these complications. METHODS Recent literature on HIV and endocrine disease was reviewed. RESULTS HIV can influence endocrine glands at several levels. Endocrine glandular function may be altered by the direct effect of HIV viral proteins, through generation of systemic and local cytokines and the inflammatory response and via glandular involvement with opportunistic infections and HIV-related malignancies. Endocrine disorders seen in people with HIV include metabolic issues related to obesity such as diabetes, hyperlipidemia, lipohypertrophy, lipoatrophy and lipodystrophy and contribute significantly to quality of life, morbidity and mortality. In addition, hypogonadism, osteopenia and osteoporosis are also more prevalent in the patients with HIV. Although disorders of hypothalamic-pituitary-adrenal axis resulting in adrenal insufficiency can be life threatening, these along with thyroid dysfunction are being seen less commonly in the antiretroviral therapy (ART) era. ARTs have greatly improved life expectancy in people living with HIV but can also have adverse endocrine effects. CONCLUSIONS Clinicians need to have a high index of suspicion for endocrine abnormalities in people with HIV as they can be potentially life threatening if untreated. Endocrine evaluation should be pursued as in the general population, with focus on prevention, early detection and treatment to improve quality of life and longevity.
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Affiliation(s)
- F S Mirza
- Division of Endocrinology and Metabolism, Department of Medicine, UConn Health, 263 Farmington Avenue, Farmington, CT, 06030-5456, USA.
- Department of Medicine, UConn Health, Farmington, CT, 06030, USA.
| | - P Luthra
- Division of Endocrinology and Metabolism, Department of Medicine, UConn Health, 263 Farmington Avenue, Farmington, CT, 06030-5456, USA
- Department of Medicine, UConn Health, Farmington, CT, 06030, USA
| | - L Chirch
- Division of Infectious Diseases, UConn Health, Farmington, CT, 06030, USA
- Department of Medicine, UConn Health, Farmington, CT, 06030, USA
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Manta A, Ugradar S, Murta F, Ezra D, Cormack I. Immune Reconstitution Inflammatory Syndrome in a Case of Nonspecific Orbital Inflammation. Ophthalmic Plast Reconstr Surg 2018; 34:e54-e56. [PMID: 29194105 DOI: 10.1097/iop.0000000000001022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The immune reconstitution inflammatory syndrome is an exaggerated abnormal immune response, typically seen in HIV-positive patients following restoration of a normal CD4 count as a result of initiation of antiretroviral therapy. It has been described in relation to either occult opportunistic infections or to a paradoxical relapse of a previously successfully treated infection with negative microbiological cultures. The authors report the case of a 60-year-old HIV-positive African male who presented with 2 episodes of orbital inflammation that occurred in conjunction with improvements of CD4 count following Highly Active Antiretroviral Therapy. This phenomenon was underpinned by biopsies obtained following each episode. Interestingly, on both occasions, he responded well to corticosteroid therapy. Although the soft tissues of the orbits are a common area affected by other inflammatory diseases, it is rare for them to be involved in immune reconstitution inflammatory syndrome. To the authors' knowledge, this is the first case report of immune reconstitution inflammatory syndrome affecting the orbits exclusively. The authors believe that it is probably an underdiagnosed condition and may be erroneously labeled as idiopathic in many cases. This case report inspires us to keep an open mind when dealing with patients on antiretroviral therapy.
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Affiliation(s)
- Alexandra Manta
- Department of Oculoplastics, Moorfields Eye Hospital, London, United Kingdom
| | | | - Fabiola Murta
- Department of Oculoplastics, Moorfields Eye Hospital, London, United Kingdom
| | - Daniel Ezra
- Department of Oculoplastics, Moorfields Eye Hospital, London, United Kingdom
| | - Ian Cormack
- Department of Oculoplastics, Moorfields Eye Hospital, London, United Kingdom
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Abstract
Immune reconstitution inflammatory syndrome (IRIS) describes a syndrome of aberrant reconstituted immunity, often in association with HIV infection, beginning with a normalization of CD4+ T-cell counts resulting in a dysregulated immune response against an infecting opportunistic pathogen and the host. In this chapter, we discuss the unique nature of IRIS when present in the central nervous system (CNS IRIS) and the changes experienced with each host pathogen and its unique influence on the immune system. Consensus on the mechanism of action of the immune system in IRIS pathology is less clear and multiple theories have been proposed. Here we explore the early history of the term IRIS, proposed mechanisms and animal models, as well as common CNS pathogens associated with IRIS, and management strategies.
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Affiliation(s)
- Lauren Bowen
- Section of Infections of the Nervous System, National Institute for Neurologic Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
| | - Avindra Nath
- Section of Infections of the Nervous System, National Institute for Neurologic Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States.
| | - Bryan Smith
- Section of Infections of the Nervous System, National Institute for Neurologic Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
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47
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Yen YF, Lan YC, Huang CT, Jen IA, Chen M, Lee CY, Chuang PH, Lee Y, Morisky DE, Chen YMA. Human Immunodeficiency Virus Infection Increases the Risk of Incident Autoimmune Hemolytic Anemia: A Population-Based Cohort Study in Taiwan. J Infect Dis 2017; 216:1000-1007. [PMID: 29149339 DOI: 10.1093/infdis/jix384] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background Currently, the association between human immunodeficiency virus (HIV) infection and subsequent development of autoimmune hemolytic anemia (AIHA) remains unclear. This nationwide population-based cohort study aimed to determine the association between incident AIHA and HIV infection in Taiwan. Methods During 2000-2012, we identified people aged ≧15 years living with HIV (PLWH) from the Taiwan Centers for Disease Control HIV Surveillance System. Individuals were considered to be infected with HIV on the basis of positive results of an HIV type 1 Western blot. Age- and sex-matched controls without HIV infection were selected from the Taiwan National Health Insurance Research Database for comparison. All patients were followed until 31 December 2012 and observed for occurrence of AIHA. Results Of 171468 subjects (19052 PLWH and 152416 controls), 30 (0.02%) had incident AIHA during a mean follow-up of 5.45 years, including 23 PLWH (0.12%) and 7 controls (0.01%). After adjustment for age, sex, and comorbidities, HIV infection was found to be an independent risk factor of incident AIHA (adjusted hazard ratio, 20.9; 95% confidence interval, 8.34-52.3). Moreover, PLWH who were receiving highly active antiretroviral therapy were more likely to develop AIHA than those who were not receiving these drugs (adjusted hazard ratio, 16.2; 95% confidence interval, 3.52-74.2). Conclusions Our study suggests that HIV infection is an independent risk factor for incident AIHA.
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Affiliation(s)
- Yung-Feng Yen
- Section of Infectious Diseases.,School of Medicine.,Center for Infectious Disease and Cancer Research
| | - Yu-Ching Lan
- Department of Health Risk Management, China Medical University, Taichung, Taiwan
| | | | - I-An Jen
- Department of Public Health, Institute of Public Health, National Yang-Ming University
| | - Marcelo Chen
- Department of Urology, Mackay Memorial Hospital.,Department of Cosmetic Applications and Management, Mackay Junior College of Medicine, Nursing, and Management
| | - Chun-Yuan Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital
| | - Pei-Hung Chuang
- Center for Prevention and Treatment of Occupational Injury and Diseases.,Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei
| | - Yun Lee
- Center for Infectious Disease and Cancer Research
| | - Donalde E Morisky
- Department of Community Health Sciences, Fielding School of Public Health, University of California at Los Angeles
| | - Yi-Ming Arthur Chen
- Center for Infectious Disease and Cancer Research.,Department of Microbiology and Institute of Medical Research, College of Medicine, Kaohsiung Medical University, Kaohsiung
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48
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Smibert OC, Trubiano JA, Cross GB, Hoy JF. Short Communication: Mycobacterium avium Complex Infection and Immune Reconstitution Inflammatory Syndrome Remain a Challenge in the Era of Effective Antiretroviral Therapy. AIDS Res Hum Retroviruses 2017; 33:1202-1204. [PMID: 28791872 DOI: 10.1089/aid.2017.0030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A 10-year review of disseminated Mycobacterium avium complex (MAC) infection and MAC-immune reconstitution inflammatory syndrome in HIV-positive patients (2004-2014) at a state-wide tertiary referral HIV service demonstrates that despite advances in antiretroviral therapy, MAC infection remains a therapeutic challenge, particularly intra-abdominal disease.
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Affiliation(s)
- Olivia C. Smibert
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Jason A. Trubiano
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Gail B. Cross
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Jennifer F. Hoy
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
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49
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Buccheri R, Benard G. Opinion: Paracoccidioidomycosis and HIV Immune Recovery Inflammatory Syndrome. Mycopathologia 2017; 183:495-498. [PMID: 29159660 DOI: 10.1007/s11046-017-0230-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 11/16/2017] [Indexed: 11/29/2022]
Abstract
Two distinct patterns of immune recovery inflammatory syndrome (IRIS) are recognized, paradoxical and unmasking IRIS. Here we raise some concerns regarding the first case of neuroPCM-IRIS published to date, as recently proposed by Almeida and Roza (Mycopathologia 177:137-141, 2017) for a patient originally described by Silva-Vergara et al. (Mycopathologia 182:393-396, 2014), taking in account the different case definitions for IRIS and the cases of neuroparacoccidioidomycosis already described in the literature. We are concerned that data from the case report have been misinterpreted and that no regard has been given to the possibility that the development of manifestations of neuroPCM after starting antiretroviral therapy and antifungal treatments could represent the predicted course of a missed neuroPCM diagnosis at presentation whose treatment failed. We hypothesize that diagnosis of the neuroPCM would not have been missed if careful screening for opportunistic infection of the central nervous system was performed prior to antiretroviral therapy initiation. Currently, there is no definitive diagnostic test for IRIS and diagnostic suspicion, as well as its management, are based on image studies and non-specific clinical signs and symptoms of inflammation. IRIS remains a diagnosis of exclusion, after considering drug toxicity, microbiologic treatment failure and the expected course of newly or previously diagnosed opportunistic infections.
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Affiliation(s)
- Renata Buccheri
- Instituto de Infectologia Emílio Ribas, São Paulo, Brazil. .,Laboratory of Medical Investigation Unit #53, Medical School and Tropical Medicine Institute, University of São Paulo Medical School, Avenida Doutor Arnaldo, 455. Cerqueira Cesar, São Paulo, SP, Brazil.
| | - Gil Benard
- Laboratories of Medical Investigation Units #53 and #56, Medical School and Tropical Medicine Institute, University of São Paulo Medical School, Avenida Doutor Arnaldo 455, São Paulo, SP, Brazil
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50
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Young J, Smith C, Teira R, Reiss P, Jarrín Vera I, Crane H, Miro JM, D'Arminio Monforte A, Saag M, Zangerle R, Bucher HC. Antiretroviral pill count and clinical outcomes in treatment-naïve patients with HIV infection. HIV Med 2017; 19:132-142. [PMID: 29110395 DOI: 10.1111/hiv.12562] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Treatment guidelines recommend single-tablet regimens for patients with HIV infection starting antiretroviral therapy. These regimens might be as effective and cost less if taken as separate drugs. We assessed whether the one pill once a day combination of efavirenz, emtricitabine and tenofovir reduces the risk of disease progression compared with multiple-pill formulations of the same regimen. METHODS We selected treatment-naïve patients starting one-, two- or three-pill formulations of this regimen in data from the Antiretroviral Therapy Cohort Collaboration. These patients were followed until an AIDS event or death or until they modified their regimen. We analysed these data using Cox regression models, then used our models to predict the potential consequences of exposing a future population to either a one-pill regimen or a three-pill regimen. RESULTS Among 11 739 treatment-naïve patients starting the regimen, there were 386 AIDS events and 87 deaths. Follow-up often ended when patients switched to the same regimen with fewer pills. After the first month, two pills rather than one was associated with an increase in the risk of AIDS or death [hazard ratio (HR) 1.39; 95% confidence interval (CI) 1.01-1.91], but three pills rather than two did not appreciably add to that increase (HR 1.19; 95% CI 0.84-1.68). We estimate that 77 patients would need to be exposed to a one-pill regimen rather than a three-pill regimen for 1 year to avoid one additional AIDS event or death. CONCLUSIONS This particular single-tablet regimen is associated with a modest decrease in the risk of AIDS or death relative to multiple-pill formulations.
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Affiliation(s)
- J Young
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - C Smith
- Research Department of Infection and Population Health, University College London, London, UK
| | - R Teira
- Unit of Infectious Diseases, Hospital Sierrallana, Torrelavega, Spain
| | - P Reiss
- Department of Internal Medicine, Division of Infectious Diseases, Center for Infection and Immunity- Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
| | - I Jarrín Vera
- National Center of Epidemiology, Carlos III Health Institute, Madrid, Spain
| | - H Crane
- Center for AIDS Research, University of Washington, Seattle, WA, USA
| | - J M Miro
- Infectious Disease Service, The Hospital Clinic of Barcelona, August Pi i Sunyer Biomedical Research Institute, University of Barcelona, Barcelona, Spain
| | - A D'Arminio Monforte
- Clinic of Infectious Diseases and Tropical Medicine, San Paolo Hospital, University of Milan, Milan, Italy
| | - M Saag
- Division of Infectious Disease, Department of Medicine, University of Alabama, Birmingham, AL, USA
| | - R Zangerle
- Medical University Innsbruck, Innsbruck, Austria
| | - H C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland.,Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
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