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Cozma EC, Banciu LM, Soare C, Găman MA, Voiculescu VM. Vasculitis-Like Hemorrhagic Herpes Zoster and HIV Infections: An Intricate Association. Cureus 2023; 15:e50609. [PMID: 38226125 PMCID: PMC10788595 DOI: 10.7759/cureus.50609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2023] [Indexed: 01/17/2024] Open
Abstract
Herein, we report the case of a 69-year-old patient who presented to our dermatology clinic for a skin eruption characterized by grouped hemorrhagic vesicles and erosions covered by hemorrhagic crusts on an erythematous background located on the lower right limb. The lesions were small, clustered, and variable in size (diameters between one and 10 mm) and located at the level of the L4-L5 dermatomes. The rash had started three to five days after the complete COVID-19 vaccination scheme with the BNT162b2 Pfizer BioNTech vaccine and had been accompanied by a flu-like syndrome. The histopathological examination established the diagnosis of leukocytoclastic vasculitis potentially in the context of a cytopathic zoster phenomenon. The atypical aspect of the zosterian eruption required additional laboratory work-up to identify possible causes of immunosuppression, i.e., screening for the presence of the human immunodeficiency virus (HIV) infection, solid cancers, as well as measurement of serum immunoglobulin concentrations, which revealed that the subject was HIV-positive. Antiviral treatment was started, with a favorable evolution of the lesions, and the patient was referred to an infectious diseases clinic for initiation of antiretroviral therapy (ART).
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Affiliation(s)
- Elena Codruța Cozma
- Pathophysiology, University of Medicine and Pharmacy of Craiova, Craiova, ROU
- Dermatology, Elias Emergency University Hospital, Bucharest, ROU
| | | | - Cristina Soare
- Dermatology, Elias Emergency University Hospital, Bucharest, ROU
| | - Mihnea-Alexandru Găman
- Hematology, Center of Hematology and Bone Marrow Transplantation, Fundeni Clinical Institute, Bucharest, ROU
- Hematology, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Vlad Mihai Voiculescu
- Dermatology, Elias Emergency University Hospital, Bucharest, ROU
- Dermatology, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
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Toljan K, Mahadeen A, Amin M, Rensel M, Jones SE, Ontaneda D, Kunchok AC. Pearls & Oy-sters: Hemorrhagic Myelitis Following SARS-CoV-2 Infection. Neurology 2023; 101:e672-e676. [PMID: 36990723 PMCID: PMC10424833 DOI: 10.1212/wnl.0000000000207213] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 02/07/2023] [Indexed: 03/31/2023] Open
Abstract
Hemorrhage in the setting of myelitis is rarely seen in clinical practice. We report a series of 3 women aged 26, 43, and 44 years, who presented with acute hemorrhagic myelitis within 4 weeks of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Two required intensive care, and 1 had severe disease with multiorgan failure. Serial MRI of the spine demonstrated T2-weighted hyperintensity with T1-weighted postcontrast enhancement in the medulla and cervical spine (patient 1) and thoracic spine (patients 2 and 3). Hemorrhage was identified on precontrast T1-weighted, susceptibility-weighted, and gradient echo sequences. Distinct from typical inflammatory or demyelinating myelitis, clinical recovery was poor in all cases, with residual quadriplegia or paraplegia, despite immunosuppression. These cases highlight that although hemorrhagic myelitis is rare, it can occur as a post/parainfectious complication of SARS-CoV-2 infection.
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Affiliation(s)
- Karlo Toljan
- From the Department of Neurology (K.T., M.A.), and Mellen Center for Multiple Sclerosis Treatment and Research (A.M., M.R., D.O., A.C.K.), Neurological Institute, and Section of Neuroradiology (S.E.J.), Imaging Institute, Cleveland Clinic, OH
| | - Ahmad Mahadeen
- From the Department of Neurology (K.T., M.A.), and Mellen Center for Multiple Sclerosis Treatment and Research (A.M., M.R., D.O., A.C.K.), Neurological Institute, and Section of Neuroradiology (S.E.J.), Imaging Institute, Cleveland Clinic, OH
| | - Moein Amin
- From the Department of Neurology (K.T., M.A.), and Mellen Center for Multiple Sclerosis Treatment and Research (A.M., M.R., D.O., A.C.K.), Neurological Institute, and Section of Neuroradiology (S.E.J.), Imaging Institute, Cleveland Clinic, OH
| | - Mary Rensel
- From the Department of Neurology (K.T., M.A.), and Mellen Center for Multiple Sclerosis Treatment and Research (A.M., M.R., D.O., A.C.K.), Neurological Institute, and Section of Neuroradiology (S.E.J.), Imaging Institute, Cleveland Clinic, OH
| | - Stephen E Jones
- From the Department of Neurology (K.T., M.A.), and Mellen Center for Multiple Sclerosis Treatment and Research (A.M., M.R., D.O., A.C.K.), Neurological Institute, and Section of Neuroradiology (S.E.J.), Imaging Institute, Cleveland Clinic, OH
| | - Daniel Ontaneda
- From the Department of Neurology (K.T., M.A.), and Mellen Center for Multiple Sclerosis Treatment and Research (A.M., M.R., D.O., A.C.K.), Neurological Institute, and Section of Neuroradiology (S.E.J.), Imaging Institute, Cleveland Clinic, OH
| | - Amy C Kunchok
- From the Department of Neurology (K.T., M.A.), and Mellen Center for Multiple Sclerosis Treatment and Research (A.M., M.R., D.O., A.C.K.), Neurological Institute, and Section of Neuroradiology (S.E.J.), Imaging Institute, Cleveland Clinic, OH.
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Tu R, Liu J, Cheng F, Weng W, Zhang H, Shu Y, Wu X, Hu Z, Zhang J. Case Report: Unusual Varicella-Zoster Virus Meningoencephalitis With Meningomyelitis Mimicking Central Nervous System Leukemia. Front Med (Lausanne) 2022; 9:847219. [PMID: 35530048 PMCID: PMC9067377 DOI: 10.3389/fmed.2022.847219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 03/14/2022] [Indexed: 12/03/2022] Open
Abstract
Background Varicella-Zoster Virus (VZV) is a human pathogen from the α-subfamily of herpesviruses. In immunocompromised patients, VZV may produce disease of the central nervous system (CNS). Clinical manifestations of CNS infection with VZV are non-specific and can mimic other infectious and non-infectious diseases. Due to similar symptoms, CNS infection with VZV represents a diagnostic challenge. Here, we report a case of a patient who showed laboratory and imaging manifestations mimicking the neoplastic etiology. Case A 31-year-old man presented with a 3-day history of headache, 5-h of confusion, generalized tonic-clonic seizures, and transient fever. The patient has a history of acute myelogenous leukemia (AML). His cerebrospinal fluid (CSF) studies revealed markedly elevated protein (10.326 g/L) and atypical cells. Meanwhile, the MRI of brain, cervical, and thoracic spine was reported as extensive (frontal, parieto-occipital and temporal pachymeningeal, and falx cerebri) enhancement and irregular thickening. These examinations suggested a suspicion of CNS involvement of AML. However, based on further investigations with metagenomic next-generation sequencing, a final diagnosis of VZV meningoencephalitis with meningomyelitis was made. With acyclovir and foscarnet sodium therapy, repeated CSF studies revealed normal cell count and protein. No atypical cells were found. The repeated brain MRI also revealed obvious resolution of the previous abnormal pachymeningeal enhancement. Conclusion This case highlights the importance of recognizing the unusual phenomenon of traditional tests in VZV meningoencephalitis with meningomyelitis, and timely using of further precise examinations to detect viral DNA, which is required to prevent missed diagnosis.
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Abstract
PURPOSE OF REVIEW Neurologists should be able to identify clinical and neuroimaging features that distinguish vascular disorders from other causes of myelopathy. RECENT FINDINGS Although certain clinical features suggest a vascular etiology in acute and chronic myelopathy settings, accurate MRI interpretation within the clinical context is key. Recent studies have shown vascular myelopathies are frequently misdiagnosed as transverse myelitis, and recognition of this diagnostic pitfall is important. Many different vascular mechanisms can cause myelopathy; this article provides a comprehensive review that simplifies disease categories into arterial ischemia, venous congestion/ischemia, hematomyelia, and extraparenchymal hemorrhage. SUMMARY It is important to recognize and manage vascular disorders of the spinal cord as significant causes of acute, subacute, and progressive myelopathy.
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Bubak AN, Como CN, Blackmon AM, Frietze S, Mescher T, Jones D, Cohrs RJ, Paucek P, Baird NL, Nagel MA. Varicella Zoster Virus Induces Nuclear Translocation of the Neurokinin-1 Receptor, Promoting Lamellipodia Formation and Viral Spread in Spinal Astrocytes. J Infect Dis 2018; 218:1324-1335. [PMID: 29788447 PMCID: PMC6129113 DOI: 10.1093/infdis/jiy297] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 05/14/2018] [Indexed: 12/11/2022] Open
Abstract
Background Varicella zoster virus (VZV) can present as a myelopathy with spinal astrocyte infection. Recent studies support a role for the neurokinin-1 receptor (NK-1R) in virus infections, as well as for cytoskeletal alterations that may promote viral spread. Thus, we examined the role of NK-1R in VZV-infected primary human spinal astrocytes (HA-sps) to shed light on the pathogenesis of VZV myelopathy. Methods Mock- and VZV-infected HA-sps were examined for substance P (subP) production, NK-1R localization, morphological changes, and viral spread in the presence or absence of the NK-1R antagonists aprepitant and rolapitant. Results VZV infection of HA-sps induced nuclear localization of full-length and truncated NK-1R in the absence of the endogenous ligand, subP, and was associated with extensive lamellipodia formation and viral spread that was inhibited by NK-1R antagonists. Conclusions We have identified a novel, subP-independent, proviral function of nuclear NK-1R associated with lamellipodia formation and viral spread that is distinct from subP-induced NK-1R cell membrane/cytoplasmic localization without lamellipodia formation. These results suggest that binding of a putative viral ligand to NK-1R produces a dramatically different NK-1R downstream effect than binding of subP. Finally, the NK-1R antagonists aprepitant and rolapitant provide promising alternatives to nucleoside analogs in treating VZV infections, including myelopathy.
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Affiliation(s)
- Andrew N Bubak
- Department of Neurology, University of Colorado School of Medicine, Aurora
| | - Christina N Como
- Department of Neurology, University of Colorado School of Medicine, Aurora
| | - Anna M Blackmon
- Department of Neurology, University of Colorado School of Medicine, Aurora
| | - Seth Frietze
- Department of Medical Laboratory and Radiation Sciences, University of Vermont, Burlington
| | - Teresa Mescher
- Department of Neurology, University of Colorado School of Medicine, Aurora
| | - Dallas Jones
- Department of Neurology, University of Colorado School of Medicine, Aurora
| | - Randall J Cohrs
- Department of Neurology, University of Colorado School of Medicine, Aurora
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora
| | - Petr Paucek
- Department of Neurology, University of Colorado School of Medicine, Aurora
| | - Nicholas L Baird
- Department of Neurology, University of Colorado School of Medicine, Aurora
| | - Maria A Nagel
- Department of Neurology, University of Colorado School of Medicine, Aurora
- Department of Ophthalmology, University of Colorado School of Medicine, Aurora
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Pohlen MS, Sunwei Lin J, Wang KY, Ghasemi-Rad M, Lincoln CM. Haemorrhagic conversion of infectious myelitis in an immunocompromised patient. BMJ Case Rep 2017; 2017:bcr-2017-221866. [PMID: 29197841 DOI: 10.1136/bcr-2017-221866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 28-year-old man recently diagnosed with HIV (CD4 19 cells/mm3, viral load 3.6 million copies/mL, not on highly active antiretroviral therapy on initial diagnosis at outside hospital), disseminated histoplasmosis, shingles and syphilis presented with paraplegia developing over 3 days. Spine MRI demonstrated a longitudinally extensive cord lesion extending from C3 to the tip of the conus. Brain MRI was consistent with meningoencephalitis. Cerebrospinal fluid findings were notable for positive varicella zoster virus (VZV) and cytomegalovirus (CMV) PCRs as well as a Venereal Disease Research Laboratory titre of 1:2. Patient was started on treatment for VZV and CMV meningoencephalitis, neurosyphilis and high-dose steroids for infectious myelitis. Repeat spine MRI demonstrated subacute intramedullary haemorrhage of the cervical cord. He was ultimately discharged to a skilled nursing facility for long-term intravenous antiviral therapy and rehabilitation. After 59 days in the hospital, his neurological exam remained grossly unchanged, with flaccid paraplegia and lack of sensation to fine touch in his lower extremities.
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Affiliation(s)
| | | | - Kevin Yuqi Wang
- Department of Radiology, Baylor College of Medicine, Houston, Texas, USA
| | | | - Christie M Lincoln
- Department of Radiology, Baylor College of Medicine, Houston, Texas, USA
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Central Nervous System Varicella Zoster Virus Vasculopathy in Human Immunodeficiency Virus Patients. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2017. [DOI: 10.1097/ipc.0000000000000491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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8
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Hemorrhagic Longitudinally Extensive Transverse Myelitis. Case Rep Neurol Med 2016; 2016:1596864. [PMID: 27847660 PMCID: PMC5099478 DOI: 10.1155/2016/1596864] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 10/03/2016] [Accepted: 10/05/2016] [Indexed: 01/08/2023] Open
Abstract
Longitudinally extensive transverse myelitis (LETM) may be associated with viral triggers, including both infections and vaccinations. We present a case of a healthy immunocompetent 33-year-old woman who developed a hemorrhagic LETM 2 weeks after seasonal influenza vaccination. Hemorrhagic LETM has not to our knowledge been reported after influenza vaccination. It may represent a forme fruste variant of acute hemorrhagic leukoencephalitis.
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Acute longitudinal and hemorrhagic myelitis caused by varicella-zoster virus in an immunocompetent adolescent. Neurologist 2016; 19:93-5. [PMID: 25888194 DOI: 10.1097/nrl.0000000000000016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES In immunocompetent person, varicella-zoster virus (VZV)-induced myelitis is rare and the lesion usually comprise focal spinal cord segment. VZV-induced hemorrhagic myelitis with lesions comprising longitudinal spinal cord has never been reported. METHODS We report a 15-year-old male patient who developed acute flaccid quadriplegia, days after a common cold. One week after the quadriplegia developed, he presented a typical herpes zoster on the lateral side of his left waist. RESULTS IgG antibody for VZV was detected in cerebrospinal fluid and the spinal cord magnetic resonance imaging findings were consistent with that of small vessel vasculitis. Treatment with acyclovir and corticosteroids resulted in no significant clinical improvement. CONCLUSIONS In this report, we wanted to emphasize the hemorrhage, the extensiveness of inflammatory changes induced by VZV in spinal cord. It is suggested that VZV should be considered as a possible cause of a severe hemorrhagic myelitis even in immunocompetent adolescent.
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Shah J, Poonawala H, Keay SK, Serulle Y, Steven A, Gandhi D, Cole JW. Varicella-Zoster Virus Vasculopathy: A Case Report Demonstrating Vasculitis using Black-Blood MRI. ACTA ACUST UNITED AC 2015; 6. [PMID: 27065314 PMCID: PMC4825687 DOI: 10.4172/2155-9562.1000342] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Infections are rare but important causes of stroke. Among these, varicella zoster virus has been known to cause ischemic stroke. During an attack of herpes zoster ophthalmicus, it has been hypothesized that the virus replicates in the trigeminal ganglion and travels via the trigeminal nerve centrally to cause cerebral vasculopathy. Here we present a case of a 69 year-old Caucasian immunocompromised woman who suffered recurrent ischemic infarcts within the same vascular distribution following an episode of zoster ophthalmicus three months prior. An imaging technique termed black-blood magnetic resonance imaging was utilized to aid in the diagnosis of cerebral vasculitis. The case is used to provide a literature review of the pathogenesis, diagnosis, and treatment of cerebral varicella zoster vasculopathy. In situations where an isolated unilateral cerebral vasculopathy is identified, neurologists are urged to consider varicella zoster as a treatable etiologic agent, as untreated vasculopathy can lead to further strokes.
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Affiliation(s)
- Jay Shah
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Husain Poonawala
- Department of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland
| | - Susan K Keay
- Department of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland ; Medical Service, VAMHCS, Baltimore, Maryland
| | - Yafell Serulle
- Department of Radiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Andrew Steven
- Department of Radiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Dheeraj Gandhi
- Department of Radiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - John W Cole
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland ; Veterans Affairs Maryland Health Care System (VAMHCS) Geriatrics Research, Education, and Clinical Center, Baltimore, Maryland
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Ferretti F, Gerevini S, Colombo B, Testa M, Guffanti M, Franciotta D, Bernardi G, Lazzarin A, Cinque P. Susac's syndrome as HIV-associated immune reconstitution inflammatory syndrome. AIDS Res Ther 2013; 10:22. [PMID: 24004690 PMCID: PMC3766273 DOI: 10.1186/1742-6405-10-22] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 08/24/2013] [Indexed: 01/08/2023] Open
Abstract
Susac’s Syndrome (SS) is an autoimmune endotheliopathy of cerebral, retinal and cochlear arterioles. We report of an HIV-infected woman who developed a first SS episode following a spontaneous reduction of plasma viral load and several relapses six years later, following initiation of combined antiretroviral therapy (cART). Corticosteroids and intravenous immunoglobulins alone did not control the disease, which improved after combined treatment with acyclovir and ganciclovir. SS onset in HIV infection and relapses during cART-induced immune reconstitution are consistent with the dysimmune nature of the disease. The response to anti-herpes drugs suggests a viral contribute in this case of SS.
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Falcone EL, Adegbulugbe AA, Sheikh V, Imamichi H, Dewar RL, Hammoud DA, Sereti I, Lane HC. Cerebrospinal fluid HIV-1 compartmentalization in a patient with AIDS and acute varicella-zoster virus meningomyeloradiculitis. Clin Infect Dis 2013; 57:e135-42. [PMID: 23728149 DOI: 10.1093/cid/cit356] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
We report a case of AIDS presenting as varicella-zoster virus (VZV) meningomyeloradiculitis associated with human immunodeficiency virus (HIV) quasispecies compartmentalization within the cerebrospinal fluid (CSF), and a CSF viral load that was 1 log higher than in peripheral blood. Prolonged antiviral therapy for both VZV and HIV type 1 was associated with partial resolution.
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Affiliation(s)
- E Liana Falcone
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland 20892-1684, USA.
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Suzuki J, Ashizawa M, Okuda S, Wada H, Sakamoto K, Terasako K, Sato M, Kimura SI, Kikuchi M, Nakasone H, Kako S, Yamazaki R, Oshima K, Nishida J, Kanda Y. Varicella zoster virus meningoencephalitis after allogeneic hematopoietic stem cell transplantation. Transpl Infect Dis 2012; 14:E7-12. [PMID: 22340704 DOI: 10.1111/j.1399-3062.2012.00720.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2011] [Revised: 11/21/2011] [Accepted: 11/26/2011] [Indexed: 12/01/2022]
Abstract
Although the reactivation of varicella zoster virus (VZV) is a common complication after allogeneic hematopoietic stem cell transplantation (HSCT), VZV meningoencephalitis is a rare life-threatening infectious disease after HSCT. We describe here a patient who developed VZV meningoencephalitis 2 years after human leukocyte antigen-matched unrelated HSCT for acute myeloblastic leukemia. She developed chronic graft-versus-host disease, and cyclosporine (CSA) was continued until 17 months after HSCT. Low-dose acyclovir (ACV) at 200 mg/day was administered to prevent the reactivation of VZV from day -7 to the termination of CSA. At 22 months, she suddenly developed fever, loss of consciousness, and seizure, with generalized skin rash. A high level of VZV DNA was detected in her cerebrospinal fluid (CSF). She was diagnosed to have VZV meningoencephalitis. Intravenous ACV at 30 mg/kg/day was given for 2 months. Although loss of consciousness was quickly resolved, some neurologic symptoms persisted. She did not have any known risk factors for VZV reactivation. Therefore, we should keep in mind that any HSCT recipient may develop VZV meningoencephalitis, and examination of CSF for VZV infection with an empiric administration of ACV may be recommended for HSCT recipients with central nervous system symptoms, even in the absence of skin manifestations.
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Affiliation(s)
- J Suzuki
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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Heinzen B, Belknap R, Symonds D, Chu ES. An IRIS to remember. Am J Med 2011; 124:e3-4. [PMID: 20851368 DOI: 10.1016/j.amjmed.2010.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2010] [Revised: 05/29/2010] [Accepted: 06/02/2010] [Indexed: 10/19/2022]
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Immune restoration diseases reflect diverse immunopathological mechanisms. Clin Microbiol Rev 2010; 22:651-63. [PMID: 19822893 DOI: 10.1128/cmr.00015-09] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Up to one in four patients infected with human immunodeficiency virus type 1 and given antiretroviral therapy (ART) experiences inflammatory or cellular proliferative disease associated with a preexisting opportunistic infection, which may be subclinical. These immune restoration diseases (IRD) appear to result from the restoration of immunocompetence. IRD associated with intracellular pathogens are characterized by cellular immune responses and/or granulomatous inflammation. Mycobacterial and cryptococcal IRD are attributed to a pathological overproduction of Th1 cytokines. Clinicopathological characteristics of IRD associated with viral infections suggest different pathogenic mechanisms. For example, IRD associated with varicella-zoster virus or JC polyomavirus infection correlate with a CD8 T-cell response in the central nervous system. Exacerbations or de novo presentations of hepatitis associated with hepatitis C virus (HCV) infection following ART may also reflect restoration of pathogen-specific immune responses as titers of HCV-reactive antibodies rise in parallel with liver enzymes and plasma markers of T-cell activation. Correlations between immunological parameters assessed in longitudinal sample sets and clinical presentations are required to illuminate the diverse immunological scenarios described collectively as IRD. Here we present salient clinical features and review progress toward understanding their pathogeneses.
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