Immune reconstitution inflammatory syndrome: emergence of a unique syndrome during highly active antiretroviral therapy

Fatal outcome of BK virus encephalitis in an allogeneic stem cell transplantation recipient

BK virus (BKV) encephalitis is a rare complication after hematopoietic stem cell transplantation (HSCT). A 43-year-old woman with recurrent follicular lymphoma after autologous HSCT received allogeneic bone marrow transplantation from a human leukocyte antigen-matched related donor. Neutrophil engraftment was achieved on post-transplant day 13. Memory loss and noncooperative attitude toward the medical staff were observed on day 16, and her mental status worsened progressively. Magnetic resonance imaging (MRI) showed nonspecific findings on day 19; however, cerebrospinal fluid (CSF) analysis including real-time polymerase chain reaction on day 20 revealed elevated levels of BKV 4.67 × 104 copy/mL. BKV encephalitis was diagnosed based on CSF findings, intravenous administration of immunoglobulin and cidofovir was started, and the immunosuppressive agent dose was reduced. Diffusion-weighted MRI on day 28 showed signal abnormalities in the bilateral periventricular white matter. Although the follow-up CSF analysis on day 35 was negative for BKV, her mental status and MRI findings did not improve, and she died on day 55 because of respiratory failure. This case emphasizes the importance of considering BKV encephalitis as a differential diagnosis of post-transplant encephalitis, considering the central nervous system-associated immune reconstitution inflammatory syndrome in patients with worsening central nervous system findings after eradication of BKV in the CSF.

HIV protease resistance mutations in patients receiving second-line antiretroviral therapy in Libreville, Gabon

INTRODUCTION

In 2022, the WHO reported that 29.8 million people around the world were living with HIV (PLHIV) and receiving antiretroviral treatment (ART), including 25‌ 375 people in Gabon (54% of all those living with HIV in the country). The literature reports a frequency of therapeutic failure with first-line antiretrovirals (ARVs) of between 20% and 82%. Unfortunately, data relating to the failure of second-line ARVs are scarce in Gabon. This study aims to determine the profiles of HIV drug resistance mutations related to protease inhibitors in Gabon.

METHODOLOGY

Plasma from 84 PLHIV receiving ARVs was collected from 2019 to 2021, followed by RNA extraction, amplification, and sequencing of the protease gene. ARV resistance profiles were generated using the Stanford interpretation algorithm version 8.9-1 ( https://hivdb.stanford.edu ) and statistical analyses were performed using EpiInfo software version 7.2.1.0 (CDC, USA).

RESULTS

Of 84 HIV plasma samples collected from 45 men and 39 women, 342 mutations were detected. Of these, 43.3% (148/342) were associated with nucleoside reverse transcriptase inhibitors (NRTIs), 30.4% (104/342) with non-nucleoside reverse transcriptase inhibitors (NNRTIs), and 26.3% (90/342) with protease inhibitors (PIs). Most NRTI mutations were associated with thymidine analogues (TAMs) (50.7%; 75/148), including T215F/V (14.9%; 22/148), D67DN/E/G/N/T (10.1%; 15/148), M41L (9.5%; 14/148), and K70E/KN/S/R (9.5%; 14/148). Resistance mutations related to non-TAM NRTIs (33.1%; 49/148) were M184V (29.1%; 43/148), and L74I/V (8.1%; 12/148). NNRTI mutations were predominantly K103N/S (32.7%; 34/104), V108I (10.6%; 11/104), A98G (10.6%; 11/104), and P225H (9.6%; 10/104). Minor mutations associated with PIs (60.0%; 54/90) were predominantly K20I (15.6%; 14/90) and L10F/I/V (14.5%; 13/90). The major mutations associated with PIs (40.0%; 36/90) were M41L (12.2%; 11/90), I84V (6.7%; 06/90), and V82A (6.7%; 06/90). The four most prescribed therapeutic regimens were TDF + 3TC + LPV/r (20.3%; 17/84), ABC + DDI + LPV/r (17.9%; 15/84), TDF + FTC + LPV/r (11.9%; 10/84), and ABC + 3TC + LPV/r (11.9%; 10/84).

CONCLUSION

This study revealed that HIV drug resistance mutations are common in Gabon. The major mutations associated with PIs were M41L, I84V, and V82A. There is a need for access to new NRTIs, NNRTIs, and PIs for a better therapeutic management of PLHIV in Gabon.

Granulomas Galore: Concomitant Granulomatous Infections in a Patient With Crohn's Disease

Tumor necrosis factor (TNF)-alpha inhibitors are effective biologics in the treatment of inflammatory bowel disease; however, they increase susceptibility to opportunistic infections. We report a case of a 74-year-old female with Crohn's disease who developed concomitant pulmonary tuberculosis (Mycobacterium tuberculosis [MTB]) and Histoplasmosis capsulatum infection while on adalimumab. Co-infection is rare in patients on TNF-alpha inhibitor therapy, and most cases have been reported in patients with human immunodeficiency virus (HIV). This was a challenging case for diagnosis and treatment due to indistinguishable presenting symptoms of both infections, similar laboratory and radiographical findings, and a clinical course complicated by drug-drug interactions and worsening of symptoms despite therapy.

Diagnostic clues in a stem cell transplant patient manifested with chronic central nervous system GVHD and IRIS

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.

Acquired immunodeficiency syndrome-related progressive multifocal leukoencephalopathy-immune reconstitution inflammatory syndrome: prevalence, main characteristics, and outcomes in a Brazilian center

BACKGROUND

Progressive multifocal leukoencephalopathy (PML) - immune reconstitution inflammatory syndrome (IRIS) in people living with HIV/AIDS (PLWHA) has been rarely described in low- and middle-income countries.

OBJECTIVE

To describe the prevalence of PML-IRIS among PLWHA with PML and its main features in a tertiary hospital in Brazil.

METHODS

We performed a retrospective cohort study. We included PLWHA with PML-IRIS patients admitted at Instituto de Infectologia Emílio Ribas, São Paulo, Brazil, between 2011 and 2021. We retrieved information on neurological manifestations, neuroimaging findings, treatments, and outcomes.

RESULTS

We identified 11 (11.8%) PML-IRIS cases among 93 patients with definite PML. Eight (73%) cases were men and had a median (IQR) age of 41 (27-50) years. Seven (63.6%) patients developed unmasking PML-IRIS and 4 (36.4%) had paradoxical PML-IRIS. The median (IQR) time from initiation of combined antiretroviral therapy (cART) to IRIS diagnosis was 49 (30-70) days. Ten (90.9%) patients received corticosteroids. There were 4 (36%) in-hospital deaths and 3 were associated with hospital-acquired pneumonia. Among the 7 (64%) patients who survived, 5 (71.5%) had sequelae at discharge. One year after the PML-IRIS diagnosis, 6 (54.5%) patients were alive.

CONCLUSION

The prevalence of PML-IRIS was 11.8%. Most patients had unmasking PML-IRIS. In-hospital mortality and morbidity were high. One-year survival was similar to that described in some high-income countries.

Unexpected exacerbation of cryptococcal meningitis after unilateral adrenalectomy in a PMAH patient: a case report and literature review

BACKGROUND

Primary bilateral macronodular adrenal hyperplasia (PMAH) combined with infection by an opportunistic pathogen is complicated. Clinical evidence on managing PMAH patients with infections by opportunistic pathogens is insufficient.

CASE PRESENTATION

A 66-year-old male was admitted with bilateral adrenal masses and was diagnosed with PMAH. Fever and disturbance of consciousness appeared after laparoscopic left adrenalectomy. Cryptococcal meningitis was confirmed by cerebrospinal fluid (CSF) culture. The exacerbation of his medical condition was suspected to result from immune reconstitution inflammatory syndrome (IRIS), and he had been treated with antifungal therapy and glucocorticoid replacement, but he responded poorly and eventually died of multiorgan failure. We summarized the clinical observations of 12 Cushing's syndrome (CS) patients infected by Cryptococcus. Seven out of nine patients who were treated for cryptococcus infection before receiving CS survived, while three patients treated for cryptococcus infection after CS treatment developed signs of IRIS and eventually died.

CONCLUSION

Cushing's syndrome, complicated with cryptococcal infection, has a high mortality rate, mainly when IRIS emerges. Carefully identifying the presence of the suspected infection, and controlling cryptococcal infection before removing the culprit adrenals could be the rational choice.

When the Cure Becomes the Problem: A Case Report of Immune Reconstitution Inflammatory Syndrome Associated With Varicella Encephalitis

Immune reconstitution inflammatory syndrome (IRIS) describes a constellation of inflammatory symptoms that develop following the initiation of antiretroviral therapy (ART) in patients with advanced human immunodeficiency virus (HIV). Here, we present a case of a 39-year-old male-to-female transgender patient with advanced HIV who was started on ART during a hospitalization for acute encephalopathy due to a combination of methicillin-resistant Staphylococcus aureus (MRSA) meningitis and varicella encephalitis. After adequate treatment of these infections and five weeks after initiation of ART, she developed inflammatory symptoms of malaise, fever, and tachycardia, as well as laboratory findings of leukocytosis consistent with an inflammatory process. Infectious workup did not reveal any evidence of a new infection, and no other undiagnosed inflammatory processes were discovered to explain these symptoms. A diagnosis of IRIS was suspected, possibly induced by a prior varicella infection. Diagnosis of IRIS can be difficult due to heterogeneous symptoms, differing etiologies, variable patient presentations, and the lack of universal diagnostic criteria. As instances of IRIS are not uncommon in patients with a low CD4 count who start on ART, there should be a high index of suspicion when patients present with inflammatory symptoms after initiation of ART. With increased recognition of the disease and improved standardization of diagnostic criteria, more could be understood about the underlying disease process which may allow for better targeted therapies and individualized treatments for patients who develop the immune reconstitution inflammatory syndrome.

Secondary Central Nervous System Demyelinating Disorders in the Elderly: A Narrative Review

Secondary demyelinating diseases comprise a wide spectrum group of pathological conditions and may either be attributed to a disorder primarily affecting the neurons or axons, followed by demyelination, or to an underlying condition leading to secondary damage of the myelin sheath. In the elderly, primary demyelinating diseases of the central nervous system (CNS), such as multiple sclerosis, are relatively uncommon. However, secondary causes of CNS demyelination may often occur and in this case, extensive diagnostic workup is usually needed. Infectious, postinfectious, or postvaccinal demyelination may be observed, attributed to age-related alterations of the immune system in this population. Osmotic disturbances and nutritional deficiencies, more commonly observed in the elderly, may lead to conditions such as pontine/extrapontine myelinolysis, Wernicke encephalopathy, and demyelination of the posterior columns of the spinal cord. The prevalence of malignancies is higher in the elderly, sometimes leading to radiation-induced, immunotherapy-related, or paraneoplastic CNS demyelination. This review intends to aid clinical neurologists in broadening their diagnostic approach to secondary CNS demyelinating diseases in the elderly. Common clinical conditions leading to secondary demyelination and their clinical manifestations are summarized here, while the current knowledge of the underlying pathophysiological mechanisms is additionally presented.

Immune Reconstitution Inflammatory Syndrome Reaction in Patient on Long-Term Prednisone

Immune reconstitution inflammatory syndrome (IRIS) can be triggered in many ways. IRIS has been recognized during tuberculosis (TB) therapy, especially in patients newly initiated on antiretroviral therapy for HIV or those taken off immunosuppressives such as tumor necrosis factor-alpha inhibitors. However, there are still many triggers of IRIS that are less understood. This case report describes a patient with scrofula that was concerning for TB reactivation, who then had subsequent IRIS. The patient had been consistently using low-dose long-term prednisone for suppression of his polymyalgia rheumatica. It is suspected that the IRIS reaction could be due to an interaction between rifampin and prednisone causing decreased efficacy of its immunosuppressive effects.

The use of TNF-α antagonists in tuberculosis to control severe paradoxical reaction or immune reconstitution inflammatory syndrome: a case series and literature review

Paradoxical reaction (PR) and immune reconstitution inflammatory syndrome (IRIS) are common complications of tuberculosis treatment. Corticosteroids are first-line treatment for severe PR or IRIS, particularly neurological. We report four cases of severe PR or IRIS during tuberculosis treatment who required TNF-α antagonists, and identified 20 additional cases through literature review. They were 14 women and 10 men, with a median age of 36 years (interquartile range, 28-52). Twelve were immunocompromised before tuberculosis: untreated HIV infection (n=6), or immunosuppressive treatment (TNF-α antagonists, n=5; tacrolimus, n=1). Tuberculosis was mostly neuromeningeal (n=15), pulmonary (n=10), lymph node (n=6), and miliary (n=6), multi-susceptible in 23 cases. PR or IRIS started after a median time of 6 weeks (IQR, 4-9) following anti-tuberculosis treatment start, and consisted primarily of tuberculomas (n=11), cerebral vasculitis (n=8), and lymphadenitis (n=6). First-line treatment of PR or IRIS was high-dose corticosteroids in 23 cases. TNF-α antagonists were used as salvage treatment in all cases, with infliximab (n=17), thalidomide (n=6), and adalimumab (n=3). All patients improved, but 6 had neurological sequelae, and 4 had TNF-α antagonist-related severe adverse events. TNF-α antagonists are safe and effective as salvage or corticosteroid-sparing therapeutic for severe PR or IRIS during tuberculosis treatment.

A case of chronic disseminated candidiasis in metamizole-induced neutropaenia

Chronic disseminated candidiasis (CDC) is a severe complication of a disseminated yeast infection mainly seen after prolonged chemotherapy-induced neutropaenia in the context of haematological malignancy. We present a case of CDC in a patient with metamizole-induced neutropaenia. To the best of our knowledge, this is the first case described in this context. Furthermore, we highlight the role of steroids in the management of this disease.

Non-infectious Uveitis as a Manifestation of the Immune Reconstitution Inflammatory Syndrome in Patients Infected by HIV

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.

Time to First Line Antiretroviral Therapy Adverse Drug Reaction and its Predictors Among Adult HIV/AIDS Patients on Treatment in Eastern Ethiopia

Background: Even though determining the time to anti-retroviral therapy (ART) adverse drug reaction and its predictors is a crucial step to overcome the negative consequences of the adverse drug reaction, there is limited information regarding the time to ART adverse drug reaction and its predictors. Therefore, this study aimed to determine the time to first ART adverse drug reaction and its predictors among adult HIV/AIDS patients on first-line antiretroviral therapy in West Hararghe Zone, Eastern Ethiopia.

Methods: An institution-based retrospective cohort study was conducted on 561 HIV/AIDS patients on first-line ART from September 2013–January 2019 at public hospitals in West Hararghe Zone, Eastern Ethiopia. Data were collected using checklists and document reviews, entered using Epi Info and analyzed in R software. A Cox proportional hazard model was fitted to identify predictors of the time to first ART adverse drug reaction. Model adequacy was checked using Cox Snell residuals. An adjusted hazard ratio with its confidence interval was used to show the presence and strength of association at a 95% confidence level.

Result: Most (90.74%) ART adverse drug reactions occurred within 1 year of initiation of ART. Overall, 54 patients developed ART adverse drug reactions with an incidence density of 3.5/100 persons-years of observations (95% CI: 2.7–4.6). The initial ART regimen (TDF, 3TC, EFV) [AHR = 0.3, 95% CI 0.1–0.7], fair adherence [AHR = 8.8, 95% CI 3.3–23.2], poor adherence [AHR = 7.8, 95% CI 3.1–19.5], moderate body mass index (BMI) at the baseline [AHR = 4.4, 95% CI 1.8–11.0], severe body mass index [AHR = 2.8, 95% CI 1.1–6.8], World Health Organization (WHO) stage II [AHR = 3.7, 95% CI 1.2–11.3] and WHO stage IV [AHR = 6.3, 95% CI 2.0–19.8] were significant predictors of the time to ART adverse drug reactions.

Conclusion: In conclusion, most of the ART adverse drug reactions occurred within 1 year of initiation of ART. The initial ART regimen (TDF, 3TC, EFV), adherence, HIV/AIDS stage, and BMI were risk factors for the time to ART adverse drug reaction. The incidence of the antiretroviral therapy adverse reaction was relatively low with early onset. Close monitoring of clients in clinical stage II and above is required and continuous assessment for improving the detection and management of adverse drug reactions is recommended. Patients with poor adherence need to get continuous counseling to improve their adherence status.

Anti-Cytomegalovirus Therapy: Whether and When to Initiate, Those Are the Questions

Cytomegalovirus (CMV) reactivation in patients with autoimmune bullous disease (AIBD) or severe drug eruption treated with immunosuppressive therapy was traditionally thought to be merely an epiphenomenon of the underlying immunosuppression. However, a detailed review of the clinical course of these patients revealed that CMV reactivation occurs upon rapid immune recovery, which is termed immune reconstitution inflammatory syndrome (IRIS), and that the timely initiation of anti-CMV therapy, when combined with maintenance doses of immunosuppressive agents, contributes to a rapid resolution of severe infectious complications thought to be refractory to conventional immunosuppressive therapies and unrelated to CMV reactivation. Thus, CMV reactivation resulting in fatal outcomes (CMV-IRIS) can be prevented by the timely detection of CMV DNA or antigens in the blood and by rapidly starting anti-CMV therapy while maintaining immunosuppressive therapy. Anti-CMV therapy is highly recommended for patients with CMV-IRIS or severe drug eruption who have risk factors for CMV reactivation resulting in fatal outcomes.

Drug allergy and non-HIV immune reconstitution inflammatory syndrome

Non-HIV immune reconstitution inflammatory syndrome (non-HIV IRIS) is associated with the recovery from an immunocompromised condition. It is defined as inflammatory disorders caused by antigens, including drugs or pathogenic microorganisms present prior to immune recovery, or by the exacerbation of an inflammatory disorder that was already present. Drug-induced hypersensitivity syndrome is a prototype of IRIS, and the pathophysiology of non-HIV IRIS can be recognized in several disorders treated with corticosteroids, immunosuppressants, molecular-targeted drugs, TNF-α antibody drugs, immune checkpoint inhibitors, and dipeptidyl peptidase-4 inhibitors. This review focuses on the relationship between the immune mechanism of non-HIV IRIS and drug allergies, especially severe drug eruption. The antigen recognition mechanism in drug allergy varies depending on the clinical type and the causative drug. The p-i concept is the main mechanism in severe drug eruption such as Stevens-Johnson syndrome/toxic epidermal necrolysis, and drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms. Lymphocytes activated by an antigen other than a drug, such as a virus, can also develop drug allergy by the loose binding of drugs with immune receptors of T cells or human leukocyte antigen. Therefore, fluctuations in the immune environment affect the onset of severe drug eruption. Novel agents that cause major changes in immunity have been marketed mainly for autoimmune diseases and malignant tumors; therefore, it is necessary to consider their effects when treating severe drug eruptions. Moreover, although a list of diagnostic criteria for this syndrome has been drafted, predictive and diagnostic biomarkers for this syndrome needs to be urgently developed.

Leprosy as immune reconstitution inflammatory syndrome in patients living with HIV: Description of French Guiana’s cases over 20 years and systematic review of the literature

Background

HIV infection is highly prevalent in French Guiana, a territory where leprosy is also endemic. Since the introduction of Highly Active Antiretroviral Treatment (HAART) in the management of HIV, leprosy has been reported as part of the immune reconstitution inflammatory syndrome (IRIS).

Methodology/Principal findings

We aimed to present a general description of these forms of leprosy as IRIS, highlighting clinical and therapeutic specificities. A retrospective study was conducted in French Guiana, including patients living with HIV (PLHIV) with advanced infection (CD4 < 200/mm3) and developing leprosy or a leprosy reaction within six months of HAART initiation, from 2000 to 2020. Clinical, histological and biological data were collected for all these patients. Six patients were reported in French Guiana. A systematic review of the literature was conducted, and its results were added to an overall analysis. Overall, seventy-three PLHIV were included. They were mainly men (74%), aged 22–54 years (median 36 years), mainly from Brazil (46.5%) and India (32.8%). Most leprosy cases (56.2%) were borderline tuberculoid (BT). Leprosy reactions were frequent (74%), mainly type 1 reaction (T1R) (68.5%), sometimes intense with ulceration of skin lesions (22%). Neuritis was observed in 30.1% of patients. The outcome was always favorable under multidrug therapy (MDT), continuation of HAART and additional corticosteroid therapy in case of neuritis or ulceration. There was no relapse.

Conclusion

Leprosy as IRIS in PLHIV mainly presents as a BT leprosy in a T1R state, sometimes with ulcerated skin lesions. Response to MDT is usually good. Systemic corticosteroids are necessary and efficient in case of neuritis.

Leprosy is an infection caused by Mycobacterium leprae characterized by skin and nerve lesions. Leprosy reactions can be observed, depending on variations in host-specific cellular immunity. Leprosy is described after antiretroviral therapy (HAART) initiation in immunocompromised PLHIV from countries where leprosy and HIV infections are endemic. This is known as immune restoration inflammatory syndrome (IRIS), a brutal inflammatory response directed against a latent or quiescent pathogen. In this study we searched for cases of leprosy as IRIS in French Guiana and those published in the literature in order to describe their clinical characteristics. Overall, our results show that these cases are mostly observed as borderline tuberculoid leprosy, associated with or quickly followed by a type 1 leprosy reaction, sometimes with neuritis and/or ulceration of lesions. The outcome is favorable under standard leprosy treatment with HAART maintenance.

Immune Reconstitution Inflammatory Syndrome Complicating Cryptococcal Meningitis in a Pediatric Heart Transplant Patient

Immune reconstitution inflammatory syndrome can be a complication of cryptococcal meningitis after immune reconstitution from antiretroviral therapy in HIV or reduced immune suppression in transplant recipients. In this case report, the authors discuss the diagnosis and management of cryptococcal-associated immune reconstitution inflammatory syndrome in a 10-year-old pediatric heart transplant recipient.

Hypercalcemia Secondary to Immune Reconstitution Inflammatory Syndrome in an HIV-Infected Individual With Mycobacterium avium Complex

Immune reconstitution inflammatory syndrome (IRIS) is an uncommon cause of hypercalcemia in HIV-infected patients recently started on highly active antiretroviral therapy (HAART). It is hypothesized that increased granulomatous formation due to IRIS leads to an overproduction of calcitriol. High levels of calcitriol, then, can lead to significant hypercalcemia. We present the case of a 63-year-old male with HIV off HAART presented to the emergency room for confusion, frequent falls, and cough. His CD-4 count was noted to be below 35 cells/µL (255-2,496). Over the course of the hospitalization, the patient was found to have disseminated Mycobacterium avium complex (MAC) infection and was initiated on HAART. Initiation of HAART was followed by an increase in calcium up to 14.1 mg/dL. The hypercalcemia did not respond to either Calcitonin or Pamidronate. Consideration was then given to IRIS in the setting of MAC infection leading to increased granulomatous formation. Calcium levels normalized within three days of therapy after initiation of prednisone for the treatment of IRIS.  It is thought that an increase in CD-4 counts leads to the recovery of an immune response. This can lead to granulomatous inflammation. An increase in granuloma formation can cause hypercalcemia due to overproduction of calcitriol via increased 1𝛼-hydroxylase activity from macrophages. Our case report describes IRIS-mediated hypercalcemia in an HIV-infected individual with MAC infection. This unusual cause of severe hypercalcemia should be considered in differential diagnoses for immunocompromised patients in the appropriate setting. Prompt treatment of IRIS with glucocorticoids can lead to the resolution of hypercalcemia.

Comparative incidence of adverse drug reaction during the first and subsequent year of antiretroviral therapy in a Nigerian HIV infected Cohort

Background

Despite close to two decades of antiretroviral therapy (ART) in Nigeria, data on late on-onset ART-associated adverse drug reactions (ADRs) are sparse.

Objectives

To describe early and late-onset ADRs and compare their incidence in an outpatient HIV positive Cohort on ART.

Method

We described the incidence of clinical ADRs identified and documented in an outpatient clinic cohort of HIV-positive patients treated between June 2004 and December 2015 at a tertiary health facility in Nigeria. Incidence rates of ADRs during the first and subsequent years of ART were compared.

Results

of the 13,983 patients' data analyzed, 9317 were females (66%), and those in the age bracket of 25 to 45 years made up 78% of the studied population. During 52,411 person-years (py) of ART, 1485 incident ADRs were recorded; Incidence rate (IR) 28.3 (95% confidence interval [CI] 26.9:29.8) ADRs per 1000 person-years (py) of ART. The IR of ADRs was about two times higher in the first year of ART compared to subsequent years of treatment; crude incidence rate ratio (IRR) 1.77 (95% CI 1.59:1.97). Anemia, hypersensitivity reactions, and nervous system disorders had 7, 23, and 5 times higher incidence, respectively, in the first year of therapy, compared to subsequent years.

Conclusion

The first year of ART is the period of highest risk of ADRs. Individual and programmatic treatment success in resource-limited settings requires strategies for early identification and management of ADR during the period of greatest risk of ADRs.

Neurologic Complications of Human Immunodeficiency Virus

PURPOSE OF REVIEW

This article reviews the neurologic complications associated with human immunodeficiency virus (HIV) infection.

RECENT FINDINGS

Neurologic complications of HIV may be caused by direct virally mediated pathology, immune-mediated phenomena in response to viral infection, or opportunistic infections secondary to depletion of lymphocytes. These neurologic disorders may be influenced by the degree of immunosuppression (ie, CD4+ T-cell lymphocyte count) and stage of infection (early versus late), as well as use of antiretroviral therapy, and may manifest as a variety of central and peripheral neurologic syndromes, including the more commonly encountered HIV-associated cognitive disorders and length-dependent sensorimotor polyneuropathy, respectively. Immune dysregulation underlies the majority of these neurologic phenomena, as well as other HIV-associated conditions including immune reconstitution inflammatory syndrome (IRIS), CD8 lymphocytosis, and potentially the development of compartmentalized infection within the CSF, also referred to as CSF escape.

SUMMARY

This article reviews a spectrum of clinical syndromes and related neuropathologic states associated with HIV infection.

Screening of Human Immunodeficiency Virus (HIV) among Newly Diagnosed Tuberculosis Patients in Eastern Sudan

Tuberculosis (TB) is a leading cause of death in patients infected with Human Immunodeficiency Virus (HIV), and HIV infection is the most potent risk factor for the development of active TB disease from a latent TB infection. This study aims to determine the seroprevalence of HIV among newly diagnosed TB patients in Kassala state eastern Sudan. This was a descriptive, hospital-based, cross-sectional study of 251 active and newly diagnosed TB patients, selected by simple random sampling. Blood samples and demographic data were collected from each patient. TB was diagnosed by direct ZN smear and molecular detection by Xpert MTB/RIF. The serum samples were tested for HIV using 4^th generation enzyme-linked immunosorbent assay (ELISA). The prevalence of HIV was 13.9% (35/251), the infection rate among pulmonary TB was 17%, whereas that in extrapulmonary TB was 4.8%, the prevalence was (18.2%) in the males, and (7.2%) in the females. In conclusion: TB/HIV co-infection in the Eastern part of Sudan was high compared with the global prevalence, all TB patients should therefore be assessed for HIV risk factors and advised to undergo HIV testing.

Heterothermy and antifungal responses in bats

Hibernation, a period where bats have suppressed immunity and low body temperatures, provides the psychrophilic fungus Pseudogymnoascus destructans the opportunity to colonise bat skin, leading to severe disease in susceptible species. Innate immunity, which requires less energy and may remain more active during torpor, can control infections with local inflammation in some bat species that are resistant to infection. If infection is not controlled before emergence from hibernation, ineffective adaptive immune mechanisms are activated, including incomplete Th1, ineffective Th2, and variable Th17 responses. The Th17 and neutrophil responses, normally beneficial antifungal mechanisms, appear to be sources of immunopathology for susceptible bat species, because they are hyperactivated after return to homeothermy. Non-susceptible species show both well-balanced and suppressed immune responses both during and after hibernation.

Safety of current immune checkpoint inhibitors in non-small cell lung cancer

Introduction: Immune checkpoint inhibitors (ICIs) achieved response rates around 20% in advanced non-small cell lung cancer (NSCLC) with 8% of patients becoming long-term survivors. Outcomes have improved with the addition of chemotherapy to immunotherapy or the combination of anti-PD(L)1 with anti-CTLA-4 agents.Areas covered: The incidence of immune-related adverse events (irAEs) in patients with NSCLC treated with ICIs varied across clinical trials and real-life studies. The onset of irAEs was 10 weeks. Toxic deaths from irAEs following anti-PD(L)1 administration resulted mainly from pneumonitis. Some irAEs such as rash and thyroiditis were probably associated with better clinical outcomes, though confounding biases exist. Investigations are on-going to determine ideal biomarkers to predict the occurrence, to screen for and to diagnose irAEs.Expert opinion: Prevention, anticipation, detection, treatment and careful monitoring are the five principles that characterize our management of irAEs. Distinguishing immune-induced pneumonitis from progression, pseudo progression, hyper progression, or other etiologies (COVID-19) can be particularly challenging in lung cancer due to the baseline vulnerable pulmonary function and thus requires caution and teamwork. We treat patients according to institutional and international guidelines and we only rechallenge them with ICIs after resolution of the AE and corticosteroid tapering.

Ecology and impacts of white-nose syndrome on bats

The recent introduction of Pseudogymnoascus destructans (the fungal pathogen that causes white-nose syndrome in bats) from Eurasia to North America has resulted in the collapse of North American bat populations and restructured species communities. The long evolutionary history between P. destructans and bats in Eurasia makes understanding host life history essential to uncovering the ecology of P. destructans. In this Review, we combine information on pathogen and host biology to understand the patterns of P. destructans spread, seasonal transmission ecology, the pathogenesis of white-nose syndrome and the cross-scale impact from individual hosts to ecosystems. Collectively, this research highlights how early pathogen detection and quantification of host impacts has accelerated the understanding of this newly emerging infectious disease.

Necrotizing periodontal diseases in human immunodeficiency virus-infected patients receiving highly active antiretroviral therapy: A review

Human immunodeficiency virus-infected patients have depleted CD4 lymphocyte counts and are susceptible to a plethora of infections of bacterial, viral, and fungal etiology. In addition to a wide range of systemic manifestations, human immunodeficiency virus-infected patients also display several characteristic oral manifestations. Studies have shown a correlation between some of the oral manifestations and CD4 lymphocyte counts which in turn is an independent prognostic indicator. To tackle the human immunodeficiency virus numerous drugs have been discovered and implemented. To overcome any potential resistance, human immunodeficiency virus patients are prescribed highly active antiretroviral therapy, wherein a combination of antiretroviral regimens are used. Studies have shown that in addition to controlling the viral activity, the treatment regimen, has a significant effect on the oral manifestations of the human immunodeficiency virus-infected patients. The present paper highlights the effects of highly active antiretroviral therapy on periodontal diseases in human immunodeficiency virus-infected individuals.

Progressive multifocal leukoencephalopathy and the spectrum of JC virus-related disease

Progressive multifocal leukoencephalopathy (PML) is a devastating CNS infection caused by JC virus (JCV), a polyomavirus that commonly establishes persistent, asymptomatic infection in the general population. Emerging evidence that PML can be ameliorated with novel immunotherapeutic approaches calls for reassessment of PML pathophysiology and clinical course. PML results from JCV reactivation in the setting of impaired cellular immunity, and no antiviral therapies are available, so survival depends on reversal of the underlying immunosuppression. Antiretroviral therapies greatly reduce the risk of HIV-related PML, but many modern treatments for cancers, organ transplantation and chronic inflammatory disease cause immunosuppression that can be difficult to reverse. These treatments — most notably natalizumab for multiple sclerosis — have led to a surge of iatrogenic PML. The spectrum of presentations of JCV-related disease has evolved over time and may challenge current diagnostic criteria. Immunotherapeutic interventions, such as use of checkpoint inhibitors and adoptive T cell transfer, have shown promise but caution is needed in the management of immune reconstitution inflammatory syndrome, an exuberant immune response that can contribute to morbidity and death. Many people who survive PML are left with neurological sequelae and some with persistent, low-level viral replication in the CNS. As the number of people who survive PML increases, this lack of viral clearance could create challenges in the subsequent management of some underlying diseases.

In this Review, Cortese et al. provide an overview of the pathobiology and evolving presentations of progressive multifocal leukoencephalopathy and other diseases caused by JC virus, and discuss emerging immunotherapeutic approaches that could increase survival.

Progressive multifocal leukoencephalopathy (PML) is a rare, debilitating and often fatal disease of the CNS caused by JC virus (JCV).

JCV establishes asymptomatic, lifelong persistent or latent infection in immune competent hosts, but impairment of cellular immunity can lead to reactivation of JCV and PML.

PML most commonly occurs in patients with HIV infection or lymphoproliferative disease and in patients who are receiving natalizumab for treatment of multiple sclerosis.

The clinical phenotype of PML varies and is shaped primarily by the host immune response; changes in the treatment of underlying diseases associated with PML have changed phenotypes over time.

Other clinical manifestations of JCV infection have been described, including granule cell neuronopathy.

Survival of PML depends on reversal of the underlying immunosuppression; emerging immunotherapeutic strategies include use of checkpoint inhibitors and adoptive T cell transfer.

Spatio-temporal Distribution of Meningitis in HIV Patients in Northern Egypt (2000-2018)

BACKGROUND

Meningitis is a leading cause of death among patients living with HIV. There is no adequate tracking of the disease occurrence, distribution and etiologic agents among this risk group in Egypt, although the pattern could differ from that of the general population.

OBJECTIVES

We aimed to describe the spatio-temporal distribution of meningitis in HIV patients in a region of Northern Egypt over 18 years (2000-2018).

METHODS

We conducted a retrospective study of 352 adult HIV patients admitted to a tertiary care fever hospital with neurological manifestations suggesting meningitis. We retrieved from inpatient records all data relevant to patient demographics, clinical presentation, diagnostic work-up, results of laboratory investigations (CSF, blood, imaging), definitive diagnosis, and in-hospital mortality.

RESULTS

The overall trend of over 2 decades showed fluctuating incidence of meningitis in HIV infected patients and increasing spread into rural areas, with a uniform circulation among adult males. Cryptococcal meningitis was the most common etiologic agent (26.9%) and was associated with worse outcomes. Focal neurological deficit (38.5%), cranial nerve involvement (48.1%) were common features in TB Meningitis. The mortality was high (56.8%) and was significantly associated with low CD4+ count, advanced AIDs clinical stage and the presence of co-morbidities.

CONCLUSION

Despite the availability of cART, meningitis, particularly cryptococcal, is common in HIV/AIDS population in Egypt. Continued efforts are desperately needed to improve the outcomes of HIV-infected patients.

Pathogenesis of Human Immunodeficiency Virus-Mycobacterium tuberculosis Co-Infection

Given that infection with Mycobacterium tuberculosis (Mtb) is the leading cause of death amongst individuals living with HIV, understanding the complex mechanisms by which Mtb exacerbates HIV infection may lead to improved treatment options or adjuvant therapies. While it is well-understood how HIV compromises the immune system and leaves the host vulnerable to opportunistic infections such as Mtb, less is known about the interplay of disease once active Mtb is established. This review explores how glutathione (GSH) depletion, T cell exhaustion, granuloma formation, and TNF-α upregulation, as a result of Mtb infection, leads to an increase in HIV disease severity. This review also examines the difficulties of treating coinfected patients and suggests further research on the clinical use of GSH supplementation.

Th1-Dependent Cryptococcus-Associated Immune Reconstitution Inflammatory Syndrome Model With Brain Damage

Cryptococcus-associated immune reconstitution inflammatory syndrome (C-IRIS) is identified upon immune reconstitution in immunocompromised patients, who have previously contracted an infection of Cryptococcus neoformans (Cn). C-IRIS can be lethal but how the immune system triggers life-threatening outcomes in patients is still poorly understood. Here, we establish a mouse model for C-IRIS with Cn serotype A strain H99, which is highly virulent and the most intensively studied. C-IRIS in mice is induced by the adoptive transfer of CD4+ T cells in immunocompromised Rag1-deficient mice infected with a low inoculum of Cn. The mice with C-IRIS exhibit symptoms which mimic clinical presentations of C-IRIS. This C-IRIS model is Th1-dependent and shows host mortality. This model is characterized with minimal lung injury, but infiltration of Th1 cells in the brain. C-IRIS mice also exhibited brain swelling with resemblance to edema and upregulation of aquaporin-4, a critical protein that regulates water flux in the brain in a Th1-dependent fashion. Our C-IRIS model may be used to advance our understanding of the paradoxical inflammatory phenomenon of C-IRIS in the context of neuroinflammation.

Immune reconstitution inflammatory syndrome in the central nervous system: Limitations for diagnosis in resource limited settings

INTRODUCTION

The diagnosis of IRIS is based on evidence of clinical worsening and immune reconstitution in the setting of combined antiretroviral therapy (cART) initiation. While central nervous system IRIS (CNS IRIS) is thought to be prevalent in resource limited settings (RLS), its identification is constrained by limited data on pre-treatment HIV disease and diagnostic testing. A diagnosis can be improved with neuroimaging and cerebrospinal fluid (CSF) studies, which are not universally available in RLS. This study evaluated whether diagnoses of CNS IRIS could be achieved in a resource limited setting based on established criteria.

METHODS

A retrospective chart review of HIV+ individuals, on ARVs at the time of presentation in two cohort studies of suspected CNS opportunistic infection or tuberculous (TB) meningitis who were admitted to a tertiary care facility in Lusaka, Zambia.

RESULTS

Using currently validated criteria, none of the 254 participants evaluated could be diagnosed with CNS IRIS, as there was no information on post-treatment trajectory of HIV viral loads or CD4 counts. Only one participant had a definitive, non-IRIS infectious diagnosis based on comprehensive testing. Of the remaining 253 patients, 68 (27%) had an identified potential CNS pathogen, 92 (36%) had inflammatory CSF in the absence of a pathogen, and 94 (37%) had normal CSF despite presenting with CNS symptoms.

CONCLUSION

The absence of HIV disease trajectory data, and lack of comprehensive diagnostic testing, compounded by a high prevalence of infectious pathogens, substantially limits the ability to diagnose CNS IRIS in RLS.

White-nose syndrome: A novel dermatomycosis of biologic interest and epidemiologic consequence

Over the past 10 years, the environmental and veterinary communities have sounded alarms over an insidious keratinophilous fungus, Pseudogymnoascus destructans, that has decimated populations of bats (yes, bats, chiropterans) throughout North America and, most recently, Northern China and Siberia. We as dermatologists may find this invasive keratinophilous fungus of particular interest, as its method of destruction is disruption of the homeostatic mechanism of the bat wing integument. Although it is unlikely that this pathogen will become an infectious threat to humans, its environmental impact will likely affect us all, especially as recent data have shown upregulation of naturally occurring coronaviruses in coinfected bats. Dermatologists are familiar with keratinophilous dermatophyte infections, but these rarely cause serious morbidity in individual patients and never cause crisis on a population basis. This contribution describes the effects of P destructans on both the individual and the population basis. Bringing the white-nose syndrome to the attention of human dermatologists and skin scientists may invite transfer of expertise in understanding the disease, its pathophysiology, epidemiology, treatment, and prevention.

Approach to an Intracranial Mass in Patients With HIV

PURPOSE OF REVIEW

Space-occupying lesions represent a diagnostic challenge among people with the human immunodeficiency virus, acquired immunodeficiency syndrome (HIV/AIDS). To determine the best diagnostic approach to the wide array of possible etiologies and provide a thorough interpretation of neuroimaging in order to narrow a hierarchical differential diagnosis among these patients. Given that there is no pathognomonic neuroimaging pattern in this clinical setting, we searched results from brain biopsies to best determine the etiology of commonly found lesions.

RECENT FINDINGS

Multimodal brain MRI and MRI spectroscopy (MRS) often provide the most valuable information in the study of focal masses among people with HIV/AIDS. Brain biopsy appears safe and provides high diagnostic yields in these patients. Among patients with HIV/AIDS who present with space-occupying intracranial lesions, brain MRI and MRS are useful tests. However, in cases of diagnostic uncertainty, brain biopsy is a safe procedure and should be performed. The role of metabolic studies like ²⁰¹Th-SPECT or PET is useful in the detection of primary central nervous system lymphoma.

Granulomatous interstitial nephritis in the setting of disseminated Mycobacterium simiae: a rare presentation of immune reconstitution inflammatory syndrome

Disseminated Mycobacterium simiae is a rare opportunistic infection reported most commonly in advanced human immunodeficiency virus (HIV) infection. Treatment can be further complicated by the occurrence of severe immune reconstitution inflammatory syndrome (IRIS). We present the first case of disseminated multi-drug-resistant M. simiae in the setting of advanced HIV, complicated by IRIS in the form of granulomatous interstitial nephritis causing acute renal failure. This case highlights the importance of recognizing rare complications of IRIS, as delays in therapy can be life threatening.

Pulmonary cryptococcal immune reconstitution syndrome in a person living with HIV: a case report

Cryptococcal immune reconstitution inflammatory syndrome (C-IRIS) in human immunodeficiency virus (HIV)-1 infection manifests as a clinical worsening or new presentation of cryptococcal disease after initiating antiretroviral therapy (ART). C-IRIS involving the respiratory system has been scarcely reported. Here, we report a case of pulmonary C-IRIS in a person living with HIV after initiating ART, characterized by an exacerbation of a pulmonary nodule and new occurrence of pleural effusions, which responded well to corticosteroid treatment.

The effect of tenofovir disoproxil fumarate on bone mineral density: a systematic review and meta-analysis

BACKGROUND

We conducted a systematic review and meta-analysis (CRD#42017070552) to quantify the impact of oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) on bone mineral density (BMD) and the risk of osteoporosis, low bone mass and fractures, among people taking it as pre-exposure prophylaxis (PrEP), HIV treatment and HBV treatment.

METHODS

We searched MEDLINE and EMBASE for randomized controlled trials published from 1997-2018 reporting BMD, osteoporosis, low bone mass and/or fractures in treatment-naive patients taking compared with not taking TDF for 48 ±4 weeks. We pooled outcomes using DerSimonian random-effects models.

RESULTS

Our search yielded 5,178 abstracts, representing 3,865 articles, with 25 meeting the inclusion criteria. TDF was associated with greater BMD decline when taken as PrEP (lumbar spine: mean difference [MD]=-0.82%, 95% CI=-1.28, -0.37%, I²=38%; total hip: MD=-0.81%, 95% CI=-1.22, -0.40%, I²=48%) and HIV treatment (lumbar spine: MD=-1.62%, 95% CI=-2.30, -0.95%, I²=93%; total hip: MD=-1.75%, 95% CI=-2.08, -1.42%, I²=83%; femoral neck: MD=-1.26%, 95% CI=-2.15, -0.38%, I²=43%) in comparison to those not taking TDF. Eight studies reported on incident osteoporosis or low bone mass, with variable results. Pooled results from five PrEP studies showed that TDF was not associated with increased fractures compared with no PrEP (RR=1.12, 95% CI=0.752, 1.74, I²=26%).

CONCLUSIONS

TDF caused greater decreases in BMD than did comparators when used for all three indications and the magnitude of this decrease was larger for HIV treatment compared with PrEP. Fractures were not increased among PrEP patients. The clinically significant BMD decline caused by TDF and current expansion of PrEP use suggest attention to the adverse bone effects of TDF will increase in importance.

A prospective study of the immune reconstitution inflammatory syndrome (IRIS) in HIV-infected children from high prevalence countries

BACKGROUND

The immune reconstitution inflammatory syndrome (IRIS) in HIV-infected infants and young children is relatively understudied in regions endemic for HIV and TB. We aimed to describe incidence, clinical features and risk factors of pediatric IRIS in Sub-Saharan Africa and India.

METHODS AND FINDINGS

We conducted an observational multi-centred prospective clinical study from December 2010 to September 2013 in children <72 months of age recruited from public antiretroviral programs. The main diagnostic criterion for IRIS was a new or worsening inflammatory event after initiating antiretroviral therapy (ART). Among 198 participants, median age 1.15 (0.48; 2.21) years, 38 children (18.8%) developed 45 episodes of IRIS. Five participants (13.2%) had two IRIS events and one (2.6%) had 3 events. Main causes of IRIS were BCG (n = 21; 46.7%), tuberculosis (n = 10; 22.2%) and dermatological, (n = 8, 17.8%). Four TB IRIS cases had severe morbidity including 1 fatality. Cytomegalovirus colitis and cryptococcal meningitis IRIS were also severe. BCG IRIS resolved without pharmacological intervention. On multivariate logistic regression, the most important baseline associations with IRIS were high HIV viral load (likelihood ratio [LR] 10.629; p = 0.0011), recruitment at 1 site (Stellenbosch University) (LR 4.01; p = 0.0452) and CD4 depletion (LR 3.4; p = 0.0654). Significantly more non-IRIS infectious and inflammatory events between days 4 and 17 of ART initiation were noted in cases versus controls (35% versus 15.2%: p = 0.0007).

CONCLUSIONS

IRIS occurs commonly in HIV-infected children initiating ART and occasionally has severe morbidity. The incidence may be underestimated. Predictive, diagnostic and prognostic biomarkers are needed.

Severe Cutaneous Adverse Reactions during Tapering of High-Dose Systemic Steroid Therapy for Autoimmune Diseases: Implications for Non-HIV Immune Reconstitution Inflammatory Syndrome

We present 2 cases of severe cutaneous adverse reactions (SCARs) during the tapering of corticosteroids, following several courses of high-dose pulse therapy for Vogt-Koyanagi-Harada disease. Their general symptoms and mucous membrane lesions, including those of the eye, were milder than those usually seen in Stevens-Johnson syndrome/toxic epidermal necrolysis. Based on their initial presentation, these cases were not initially identified as SCARs, but continued to progress over the course of a few days. The mechanism underlying the paradoxical response to steroid administration seen in these patients can be interpreted as immune reconstitution inflammatory syndrome in human immunodeficiency virus-negative patients.

Concomitant pulmonary sarcoidosis and HIV infection: A case report

RATIONALE

Sarcoidosis is an immune-mediated systemic disease, and the increase in CD4+ T lymphocyte cells is considered as a key factor for the development of sarcoidosis. The acquired immune deficiency syndrome (AIDS) is well known as the impaired immune system and characterized by relative lack of CD4+ T lymphocytes. Thus, the coexistence of sarcoidosis and HIV infection has rarely been reported.

PATIENT CONCERNS

A 65-year-old female patient was admitted to our respiratory ward complained of fatigue, chest distress, and a persistent dry cough for 2 months.

DIAGNOSES

The chest computed tomography scan showed diffuse reticulonodular infiltrates and mediastinal and hilar lymphadenopathy. Fibreoptic bronchoscopy along with transbronchial biopsy and transbronchial needle aspiration was performed. The pathological findings revealed noncaseating granulomas, and the patient was found to be HIV-seropositive through enzyme-linked immunosorbent assay and confirmed as HIV by the centers for disease control and prevention.

INTERVENTIONS

The patient was administered oral methylprednisolone 20 mg/day for pulmonary sarcoidosis and then referred to the hospital for infectious diseases receiving subsequent treatment for HIV.

OUTCOMES

clinical symptoms relieved 3 months later after treatment.

LESSONS

The coexistence of sarcoidosis and HIV infection is rare because of paradoxical roles of CD4-positive T cells in the pathogenesis of AIDS and sarcoidosis.

Tuberculosis and HIV-An Update on the "Cursed Duet" in Children

HIV and tuberculosis (TB) often occur together with each exacerbating the other. Improvements in vertical transmission prevention has reduced the number of HIV-infected children being born and early antiretroviral therapy (ART) protects against tuberculosis. However, with delayed HIV diagnosis, HIV-infected infants often present with tuberculosis co-infection. The number of HIV exposed uninfected children has increased and these infants have high exposure to TB and may be more immunologically vulnerable due to HIV exposure in utero. Bacillus Calmette-Guérin (BCG) immunization shortly after birth is essential for preventing severe TB in infancy. With early infant HIV diagnosis and ART, disseminated BCG is no longer an issue. TB prevention therapy should be implemented for contacts of a source case and for all HIV-infected individuals over a year of age. Although infection can be identified through skin tests or interferon gamma release assays, the non-availability of these tests should not preclude prevention therapy, once active TB has been excluded. Therapeutic options have moved from isoniazid only for 6-9 months to shorter regimens. Prevention therapy after exposure to a source case with resistant TB should also be implemented, but should not prevent pivotal prevention trials already under way. A microbiological diagnosis for TB remains the gold standard because of increasing drug resistance. Antiretroviral therapy for rifampicin co-treatment requires adaptation for those on lopinavir-ritonavir, which requires super-boosting with additional ritonavir. For those with drug resistant TB, the main problems are identification and overlapping toxicity between antiretroviral and anti-TB therapy. In spite of renewed focus and improved interventions, infants are still vulnerable to TB.

Predictors of immunotherapy-induced immune-related adverse events

Purpose

We aimed to elucidate predictive factors for the development of immune-related adverse events (iraes) in patients receiving immunotherapies for the management of advanced solid cancers.

Methods

This retrospective study involved all patients with histologically confirmed metastatic or inoperable melanoma, non-small-cell lung cancer, or renal cell carcinoma receiving immunotherapy at the Cancer Centre of Southeastern Ontario. The type and severity of iraes, as well as potential protective and exacerbating factors, were collected from patient charts.

Results

The study included 78 patients receiving ipilimumab (32%), nivolumab (33%), or pembrolizumab (35%). Melanoma, non-small-cell lung cancer, and renal cell carcinoma accounted for 70%, 22%, and 8% of the cancers in the study population. In 41 patients (53%) iraes developed, with multiple iraes developing in 12 patients (15%). In most patients (70%), the iraes were of severity grade 1 or 2. Female sex [adjusted odds ratio (or_adj): 0.094; 95% confidence interval (ci): 0.021 to 0.415; p = 0.002] and corticosteroid use before immunotherapy (or_adj: 0.143; 95% ci: 0.036 to 0.562; p = 0.005) were found to be associated with a protective effect against iraes. In contrast, a history of autoimmune disease (or_adj: 9.55; 95% ci: 1.34 to 68.22; p = 0.025), use of ctla-4 inhibitors (or_adj: 6.25; 95% ci: 1.61 to 24.25; p = 0.008), and poor kidney function of grade 3 or greater (or_adj: 10.66; 95% ci: 2.41 to 47.12; p = 0.025) were associated with a higher risk of developing iraes. A Hosmer-Lemeshow goodness-of-fit test demonstrated that the logistic regression model was effective at predicting the development of iraes (chi-square: 1.596; df = 7; p = 0.979).

Conclusions

Our study highlights several factors that affect the development of iraes in patients receiving immunotherapy. Although future studies are needed to validate the resulting model, findings from the study can help to guide risk stratification, monitoring, and management of iraes in patients given immunotherapy for advanced cancer.

High mortality in peritonitis due to Mycobacterium avium complex: retrospective study and systematic literature review

BACKGROUND

Mycobacterium avium complex (MAC) infection is often disseminated and mainly involves lymph nodes, spleen, liver or bone marrow. Peritonitis due to MAC infection (PMAC) is a very uncommon manifestation.

METHODS

In this report, after describing the case of the only PMAC infection in our 10-year retrospective study, which occurred in an AIDS patient who was non-adherent to highly active antiretroviral therapy (HAART), we performed a systematic literature review of documented bacteriological PMAC.

RESULTS

Including our patient, 51 cases of PMAC have been reported. Patients were most often male (sex ratio 2.14), with a median age of 41 years (2.8-72) and an immunodeficiency in all cases, most often AIDS (57%), cirrhosis (20%) and continuous ambulatory peritoneal dialysis (CAPD) (18%). Ascites was more often chylous (54%) than exudative (46%) and, in this case, lymphocytic (60%), with an inconstantly positive acid-fast bacilli smear (54%). Non-disseminated PMAC patients were more likely to have peritoneal dialysis (39% versus 6.5%, p < .01) or cancer with immunosuppressive therapy (39% versus 0%, p < .0001), while AIDS was the leading underlying disease in disseminated-PMAC patients (83% versus 11%, p < .001). Mortality was high (50%), with no difference between disseminated and non-disseminated PMAC.

CONCLUSIONS

This report highlights the need to be aware of an atypical presentation of PMAC infection, which is associated with a high rate of mortality even for non-disseminated infection.

Extracorporeal life support for immune reconstitution inflammatory syndrome in HIV patients with Pneumocystis jirovecii pneumonia

Patients with immunosuppression from human immunodeficiency virus (HIV) have been traditionally considered poor candidates for extracorporeal membrane oxygenation (ECMO) because of high in-hospital mortality and poor long-term survival. Highly active antiretroviral therapy (HAART) has improved survival rates in compliant HIV patients and reversible severe respiratory failure may warrant ECMO in this group. Immune reconstitution inflammatory syndrome (IRIS) involves excessive inflammatory response to a pathogen with paradoxical clinical deterioration following HAART initiation and may present as severe respiratory failure. Patients with IRIS supported on ECMO have been infrequently reported in literature. We report two HIV-positive patients who developed acute respiratory distress syndrome from IRIS necessitating successful veno-venous ECMO as salvage therapy.

Effects of HIV infection and ART on phenotype and function of circulating monocytes, natural killer, and innate lymphoid cells

HIV infection causes upregulation of markers of inflammation, immune activation and apoptosis of host adaptive, and innate immune cells particularly monocytes, natural killer (NK) and innate lymphoid cells (ILCs). Although antiretroviral therapy (ART) restores CD4 T-cell counts, the persistent aberrant activation of monocytes, NK and ILCs observed likely contributes to the incomplete recovery of T-cell effector functions. A better understanding of the effects of HIV infection and ART on the phenotype and function of circulating monocytes, NK, and ILCs is required to guide development of novel therapeutic interventions to optimize immune recovery.

First case of acute granulomatous interstitial nephritis with immune reconstitution inflammatory syndrome in a patient with HIV coinfected with disseminated Mycobacterium kansasii

Restoration of immune response by highly active antiretroviral therapy (HAART) effectively improved the overall prognosis of HIV infection. However, 25%-31.7% of patients experience paradoxical worsening of pre-existing infections or unmasking of subclinical infections after starting HAART therapy, which is termed as immune reconstitution inflammatory syndrome (IRIS). Acute granulomatous interstitial nephritis as a consequence of IRIS has never been reported with Mycobacteriumkansasiicoinfection. Here, we describe an HIV/AIDS patient coinfected with disseminated M. kansasii infection, who presented with acute kidney injury 4.5 months after initiation of HAART. The diagnostic workup revealed IRIS was the cause of acute kidney injury. Short-term course of prednisone (1 mg/kg/day) along with antimycobacterial and HAART regimen achieved significant improvement.

A Case of Erythema Multiforme Major Developed after Sequential Use of Two Immune Checkpoint Inhibitors, Nivolumab and Ipilimumab, for Advanced Melanoma: Possible Implication of Synergistic and/or Complementary Immunomodulatory Effects

Immune checkpoint inhibitors, such as ipilimumab and nivolumab, reverse the imbalance of antitumor self-tolerance and enhance T-cell responses. Currently, ipilimumab and nivolumab have a reported therapeutic impact on unresectable or metastatic melanomas; however, they also induce immune-related adverse events (irAEs). Ipilimumab-induced cutaneous irAEs are mostly low grade and manageable, although all-grade rash may occur in approximately 45% of all patients. We here report the case of a young woman with erythema multiforme major, which developed after sequential use of these 2 immune checkpoint inhibitors for advanced melanoma of the scalp. Initially, she received 12 cycles of nivolumab monotherapy followed by ipilimumab. A week later, multiple erythematous papulo-erythemas appeared on almost her entire body, with high-grade fever, mucosal involvements, and dyspnea. Immunohistochemistry using the lesioned skin revealed lymphocytic infiltration predominantly positive for CD8, contrasting with those for CD4 and Foxp3. Ipilimumab was stopped but she continued to receive empirical antibiotics; additionally, she was treated with intravenous steroid pulse therapy and immunoglobulin, followed by oral prednisolone. Her symptoms subsided rapidly, allowing a restart of nivolumab monotherapy alone. In our case, the long-standing preceding nivolumab monotherapy may synergistically and/or complementary have contributed to – in combination with the later administration of ipilimumab – recover antigen-responsive T-cell immunity, which is similar to the concept of immune reconstitution inflammatory syndrome, resulting in the establishment of an underlying immunopathology of erythema multiforme and life-threatening airway obstruction.

Disseminated Cryptococcosis with Marked Eosinophilia in a Postpartum Woman

Disseminated cryptococcosis usually develops in immunosuppressed patients. A 33-year-old postpartum woman developed disseminated cryptococcosis with marked eosinophilia. She presented with a cough and a week-long fever. A computed tomography scan showed multiple pulmonary nodules randomly distributed. Eosinophils were observed to have increased in number in both her peripheral blood and bronchoalveolar lavage fluid. A transbronchial lung biopsy and cerebrospinal fluid specimens revealed findings consistent with cryptococcal infection. Disseminated cryptococcosis can present with marked eosinophilia of the peripheral blood and lung tissues. Additionally, the postpartum immune status may sometimes be involved in the development of opportunistic infections in previously healthy women.