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Dupnik K, Rivera VR, Dorvil N, Duffus Y, Akbarnejad H, Gao Y, Liu J, Apollon A, Dumont E, Riviere C, Severe P, Lavoile K, Duran Mendicuti MA, Pierre S, Rouzier V, Walsh KF, Byrne AL, Joseph P, Cremieux PY, Pape JW, Koenig SP. Potential Utility of C-reactive Protein for Tuberculosis Risk Stratification Among Patients With Non-Meningitic Symptoms at HIV Diagnosis in Low- and Middle-income Countries. Open Forum Infect Dis 2024; 11:ofae356. [PMID: 39022393 PMCID: PMC11252845 DOI: 10.1093/ofid/ofae356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 06/27/2024] [Indexed: 07/20/2024] Open
Abstract
Background The World Health Organization recommends initiating same-day antiretroviral therapy (ART) while tuberculosis (TB) testing is under way for patients with non-meningitic symptoms at HIV diagnosis, though safety data are limited. C-reactive protein (CRP) testing may improve TB risk stratification in this population. Methods In this baseline analysis of 498 adults (>18 years) with TB symptoms at HIV diagnosis who were enrolled in a trial of rapid ART initiation in Haiti, we describe test characteristics of varying CRP thresholds in the diagnosis of TB. We also assessed predictors of high CRP as a continuous variable using generalized linear models. Results Eighty-seven (17.5%) participants were diagnosed with baseline TB. The median CRP was 33.0 mg/L (interquartile range: 5.1, 85.5) in those with TB, and 2.6 mg/L (interquartile range: 0.8, 11.7) in those without TB. As the CRP threshold increased from ≥1 mg/L to ≥10 mg/L, the positive predictive value for TB increased from 22.4% to 35.4% and negative predictive value decreased from 96.9% to 92.3%. With CRP thresholds varying from <1 to <10 mg/L, a range from 25.5% to 64.9% of the cohort would have been eligible for same-day ART and 0.8% to 5.0% would have untreated TB at ART initiation. Conclusions CRP concentrations can be used to improve TB risk stratification, facilitating same-day decisions about ART initiation. Depending on the CRP threshold, one-quarter to two-thirds of patients could be eligible for same-day ART, with a reduction of 3- to 20-fold in the proportion with untreated TB, compared with a strategy of same-day ART while awaiting TB test results.
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Affiliation(s)
- Kathryn Dupnik
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Vanessa R Rivera
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Nancy Dorvil
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Yanique Duffus
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | | | - Yipeng Gao
- The Analysis Group, Boston, Massachusetts, USA
| | - Jingyi Liu
- The Analysis Group, Boston, Massachusetts, USA
| | - Alexandra Apollon
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Emelyne Dumont
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Cynthia Riviere
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Patrice Severe
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Kerlyne Lavoile
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | - Samuel Pierre
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Vanessa Rouzier
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
- St. Vincent's Hospital and Clinical School, University of New South Wales, Darlinghurst, New South Wales, Australia
| | - Kathleen F Walsh
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Anthony L Byrne
- St. Vincent's Hospital and Clinical School, University of New South Wales, Darlinghurst, New South Wales, Australia
| | - Patrice Joseph
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | - Jean William Pape
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
- St. Vincent's Hospital and Clinical School, University of New South Wales, Darlinghurst, New South Wales, Australia
| | - Serena P Koenig
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Mertens J, Laghrib Y, Kenyon C. A Case of Steroid-Responsive, COVID-19 Immune Reconstitution Inflammatory Syndrome Following the Use of Granulocyte Colony-Stimulating Factor. Open Forum Infect Dis 2020; 7:ofaa326. [PMID: 32855992 PMCID: PMC7443106 DOI: 10.1093/ofid/ofaa326] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/27/2020] [Indexed: 01/06/2023] Open
Abstract
We present a case report of a 54-year-old male with metastasized nasopharyngeal carcinoma presenting to the hospital with dyspnea, anorexia and fever. Examination revealed chemotherapy-induced pancytopenia. The patient tested positive for SARSCoV-2, but respiratory complications were mild. The patient was treated with granulocyte-colony stimulating factor (G-CSF) leading to amelioration of the neutropenia. However, severe acute respiratory distress syndrome (ARDS) occurred, prompting the diagnosis of immune reconstitution inflammatory syndrome (IRIS). GCSF is currently investigated as additional therapy in ARDS, but this case report emphasizes that risks and benefits must be carefully assessed. To our knowledge, this is the first case report of IRIS-induced ARDS in a COVID-19 patient.
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Affiliation(s)
- Jonathan Mertens
- Department of Internal Medicine, University Hospital Antwerp, Antwerp, Belgium
| | - Yassine Laghrib
- Department of Internal Medicine, University Hospital Antwerp, Antwerp, Belgium
| | - Chris Kenyon
- HIV/STI Unit, Institute of Tropical Medicine, Department of Clinical Sciences, Antwerp, Belgium.,Division of Infectious Diseases and HIV Medicine, University of Cape Town, Observatory, South Africa
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de Sá NBR, Ribeiro-Alves M, da Silva TP, Pilotto JH, Rolla VC, Giacoia-Gripp CBW, Scott-Algara D, Morgado MG, Teixeira SLM. Clinical and genetic markers associated with tuberculosis, HIV-1 infection, and TB/HIV-immune reconstitution inflammatory syndrome outcomes. BMC Infect Dis 2020; 20:59. [PMID: 31959123 PMCID: PMC6971853 DOI: 10.1186/s12879-020-4786-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 01/09/2020] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Tuberculosis (TB) and AIDS are the leading causes of infectious disease death worldwide. In some TB-HIV co-infected individuals treated for both diseases simultaneously, a pathological inflammatory reaction termed immune reconstitution inflammatory syndrome (IRIS) may occur. The risk factors for IRIS are not fully defined. We investigated the association of HLA-B, HLA-C, and KIR genotypes with TB, HIV-1 infection, and IRIS onset. METHODS Patients were divided into four groups: Group 1- TB+/HIV+ (n = 88; 11 of them with IRIS), Group 2- HIV+ (n = 24), Group 3- TB+ (n = 24) and Group 4- healthy volunteers (n = 26). Patients were followed up at INI/FIOCRUZ and HGNI (Rio de Janeiro/Brazil) from 2006 to 2016. The HLA-B and HLA-C loci were typed using SBT, NGS, and KIR genes by PCR-SSP. Unconditional logistic regression models were performed for Protection/risk estimation. RESULTS Among the individuals with TB as the outcome, KIR2DS2 was associated with increased risk for TB onset (aOR = 2.39, P = 0.04), whereas HLA-B*08 and female gender were associated with protection against TB onset (aOR = 0.23, P = 0.03, and aOR = 0.33, P = 0.01, respectively). Not carrying KIR2DL3 (aOR = 0.18, P = 0.03) and carrying HLA-C*07 (aOR = 0.32, P = 0.04) were associated with protection against TB onset among HIV-infected patients. An increased risk for IRIS onset was associated with having a CD8 count ≤500 cells/mm3 (aOR = 18.23, P = 0.016); carrying the KIR2DS2 gene (aOR = 27.22, P = 0.032), the HLA-B*41 allele (aOR = 68.84, P = 0.033), the KIR2DS1 + HLA-C2 pair (aOR = 28.58, P = 0.024); and not carrying the KIR2DL3 + HLA-C1/C2 pair (aOR = 43.04, P = 0.034), and the KIR2DL1 + HLA-C1/C2 pair (aOR = 43.04, P = 0.034), CONCLUSIONS: These results suggest the participation of these genes in the immunopathogenic mechanisms related to the conditions studied. This is the first study demonstrating an association of HLA-B*41, KIR2DS2, and KIR + HLA-C pairs with IRIS onset among TB-HIV co-infected individuals.
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Affiliation(s)
- Nathalia Beatriz Ramos de Sá
- Laboratory of AIDS & Molecular Immunology, Oswaldo Cruz Institute, FIOCRUZ. Av. Brasil 4365, Leonidas Deane Building, room 401, Rio de Janeiro, 21040-360, Brazil
| | - Marcelo Ribeiro-Alves
- Laboratory of Clinical Research on STD/AIDS, National Institute of Infectious Diseases Evandro Chagas, FIOCRUZ, Rio de Janeiro, Brazil
| | - Tatiana Pereira da Silva
- Laboratory of AIDS & Molecular Immunology, Oswaldo Cruz Institute, FIOCRUZ. Av. Brasil 4365, Leonidas Deane Building, room 401, Rio de Janeiro, 21040-360, Brazil
| | - Jose Henrique Pilotto
- Laboratory of AIDS & Molecular Immunology, Oswaldo Cruz Institute, FIOCRUZ. Av. Brasil 4365, Leonidas Deane Building, room 401, Rio de Janeiro, 21040-360, Brazil
- Nova Iguaçu General Hospital, Nova Iguaçu, Rio de Janeiro, Brazil
| | - Valeria Cavalcanti Rolla
- Clinical Research Laboratory on Mycobacteria, National Institute of Infectious Diseases Evandro Chagas, FIOCRUZ, Rio de Janeiro, Brazil
| | - Carmem B W Giacoia-Gripp
- Laboratory of AIDS & Molecular Immunology, Oswaldo Cruz Institute, FIOCRUZ. Av. Brasil 4365, Leonidas Deane Building, room 401, Rio de Janeiro, 21040-360, Brazil
| | - Daniel Scott-Algara
- Unité de Biologie Cellulaire des Lymphocytes, Institut Pasteur, Paris, France
| | - Mariza Gonçalves Morgado
- Laboratory of AIDS & Molecular Immunology, Oswaldo Cruz Institute, FIOCRUZ. Av. Brasil 4365, Leonidas Deane Building, room 401, Rio de Janeiro, 21040-360, Brazil.
| | - Sylvia Lopes Maia Teixeira
- Laboratory of AIDS & Molecular Immunology, Oswaldo Cruz Institute, FIOCRUZ. Av. Brasil 4365, Leonidas Deane Building, room 401, Rio de Janeiro, 21040-360, Brazil
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Hemophagocytic Lymphohistiocytosis in an AIDS Patient with Kaposi Sarcoma: A Treatment Dilemma. Case Rep Hematol 2019; 2019:7634760. [PMID: 31687230 PMCID: PMC6800897 DOI: 10.1155/2019/7634760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 09/16/2019] [Indexed: 11/17/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a result of an abnormal activation of immune cells (T lymphocytes, natural killer cells, and macrophages) resulting in cytokine overproduction and immune destruction of cells, eventually resulting in multiorgan failure. Genetic causes are responsible for primary hemophagocytosis, but malignancies, infections, and autoimmunity underlie most of the secondary cases. We present an unusual case of a patient with AIDS and disseminated Kaposi sarcoma who was commenced on highly active antiretroviral therapy (HAART) but developed HLH secondary to immune reconstitution inflammatory syndrome (IRIS). We report this case to highlight the difficulty in managing this patient given the complex interplay of immunosuppression due to AIDS, immune reconstitution following initiation of HAART, and immune overdrive manifesting as HLH.
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Cresswell FV, Te Brake L, Atherton R, Ruslami R, Dooley KE, Aarnoutse R, Van Crevel R. Intensified antibiotic treatment of tuberculosis meningitis. Expert Rev Clin Pharmacol 2019; 12:267-288. [PMID: 30474434 DOI: 10.1080/17512433.2019.1552831] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Meningitis is the most severe manifestation of tuberculosis, resulting in death or disability in over 50% of those affected, with even higher morbidity and mortality among patients with HIV or drug resistance. Antimicrobial treatment of Tuberculous meningitis (TBM) is similar to treatment of pulmonary tuberculosis, although some drugs show poor central nervous system penetration. Therefore, intensification of antibiotic treatment may improve TBM treatment outcomes. Areas covered: In this review, we address three main areas: available data for old and new anti-tuberculous agents; intensified treatment in specific patient groups like HIV co-infection, drug-resistance, and children; and optimal research strategies. Expert commentary: There is good evidence from preclinical, clinical, and modeling studies to support the use of high-dose rifampicin in TBM, likely to be at least 30 mg/kg. Higher dose isoniazid could be beneficial, especially in rapid acetylators. The role of other first and second line drugs is unclear, but observational data suggest that linezolid, which has good brain penetration, may be beneficial. We advocate the use of molecular pharmacological approaches, physiologically based pharmacokinetic modeling and pharmacokinetic-pharmacodynamic studies to define optimal regimens to be tested in clinical trials. Exciting data from recent studies hold promise for improved regimens and better clinical outcomes in future.
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Affiliation(s)
- Fiona V Cresswell
- a Clinical Research Department , London School of Hygiene and Tropical Medicine , London , UK.,b Research Department , Infectious Diseases Institute , Kampala , Uganda
| | - Lindsey Te Brake
- c Department of Pharmacy , Radboud Institute of Health Sciences, Radboud Center for Infectious Diseases Radboud university medical center , Nijmegen , The Netherlands
| | - Rachel Atherton
- b Research Department , Infectious Diseases Institute , Kampala , Uganda
| | - Rovina Ruslami
- d TB-HIV Research Centre, Faculty of Medicine , Universitas Padjadjaran , Bandung , Indonesia
| | - Kelly E Dooley
- e Divisions of Clinical Pharmacology and Infectious Diseases, Department of Medicine , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Rob Aarnoutse
- c Department of Pharmacy , Radboud Institute of Health Sciences, Radboud Center for Infectious Diseases Radboud university medical center , Nijmegen , The Netherlands
| | - Reinout Van Crevel
- f Department of Internal Medicine and Radboud Center for Infectious Diseases , Radboud university medical center , Nijmegen , the Netherlands.,g Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine , University of Oxford , Oxford , UK
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Aberrant plasma MMP and TIMP dynamics in Schistosoma - Immune reconstitution inflammatory syndrome (IRIS). PLoS Negl Trop Dis 2018; 12:e0006710. [PMID: 30089120 PMCID: PMC6101407 DOI: 10.1371/journal.pntd.0006710] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 08/20/2018] [Accepted: 07/22/2018] [Indexed: 11/19/2022] Open
Abstract
Background Among the different faces of immune reconstitution inflammatory syndrome (IRIS) developing in HIV-patients, no clinical definition has been reported for Schistosomiasis-IRIS (Schisto-IRIS). Although Schisto-IRIS remains largely uninvestigated, matrix metalloproteinases (MMP) and tissue inhibitors of metalloproteinases (TIMP) have previously been associated with S. mansoni infection and tuberculosis-IRIS. Here, we aimed to investigate the relevance of these markers in Schisto-IRIS. Methodology Patients were diagnosed with IRIS related to S. mansoni within a cohort of patients with Schistosomiasis-HIV co-infection, using a clinical working definition of Schisto-IRIS. We compared 9 patients who developed Schisto-IRIS to 9 Schisto+HIV+ controls who did not, and 9 Schisto-HIV+ controls. Plasma levels of MMP-1, MMP-7, MMP-10, TIMP-1, TIMP-2, sCD14, intestinal fatty-acid binding protein, C-reactive protein, and 8 anti-nuclear antibodies (ANA) were analyzed prior to and during 3 months of ART. Principal findings Although no differences were observed for MMP-1 and -7, MMP-10 levels decreased significantly in Schisto+HIV+ controls during 3 months of ART (p = 0.005) while persisting in Schisto-IRIS patients at significantly higher levels compared to Schisto-HIV+ controls (p≤0.030). In contrast TIMP-1 levels only decreased significantly in Schisto-IRIS patients (p = 0.012), while TIMP-2 levels were lower compared to Schisto+HIV+ controls at 2 weeks (p = 0.007), 1 month (p = 0.005) and 3 months (p = 0.031) of ART. Five out of 8 ANAs studied decreased significantly in Schisto-IRIS patients after 1 month of ART(p≤0.039), whereas only 1 ANA decreased for Schisto+HIV+ controls (p = 0.027). Conclusions/Significance In this study, we propose a working definition for the diagnosis of Schisto-IRIS in resource limited settings. We report persistent plasma levels of MMP-10, along with a more pronounced decrease in TIMP-1 and ANA-levels, and low levels of TIMP-2 during 3 months of ART. Corresponding to the clinical symptoms, these data suggest that Schisto-IRIS is marked by unbalanced MMP/TIMP dynamics which favor inflammation. A subset of HIV-patients starting antiretroviral therapy are at risk of developing immune-driven worsening symptoms of a previously treated opportunistic infection. This paradoxical immune reconstitution inflammatory syndrome (IRIS) has been abundantly described in common co-infections such as M. tuberculosis (TB-IRIS), whereas IRIS associated with Schistosoma mansoni (Schisto-IRIS) is less well studied. Nonetheless, HIV and S. mansoni are highly co-endemic in Sub-Saharan Africa and the considerable clinical burden of Schisto-IRIS in the field should not be underestimated. Moreover, no clinical definition exists to help diagnose this complication. Although little is known about the immune dysregulation in Schisto-IRIS, matrix metalloproteinases (MMPs) and tissue inhibitor of metalloproteinases (TIMPs) have been linked to schistosomiasis and TB-IRIS on account of their role in tissue-destructive inflammation. The current study is nested within a three-month case-control study in schistosomiasis/HIV co-infected fishermen starting ART in Kenya. We propose a clinical working definition for Schisto-IRIS, based on critical evaluation of symptoms developing during ART. Our study now links aberrant dynamics of MMPs and TIMPs to Schisto-IRIS as well. Given the role of MMPs and TIMPs in tissue remodeling and inflammation, our findings suggest that Schisto-IRIS is marked by unbalanced MMP/TIMP dynamics that favor inflammation.
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Bell L, Peyper JM, Garnett S, Tadokera R, Wilkinson R, Meintjes G, Blackburn JM. TB-IRIS: Proteomic analysis of in vitro PBMC responses to Mycobacterium tuberculosis and response modulation by dexamethasone. Exp Mol Pathol 2017; 102:237-246. [PMID: 28209523 PMCID: PMC5446321 DOI: 10.1016/j.yexmp.2017.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 02/11/2017] [Indexed: 12/02/2022]
Abstract
Paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) occurs in 8-54% of South African patients undergoing treatment for tuberculosis/human immunodeficiency virus co-infection. Improved TB-IRIS molecular pathogenesis understanding would enhance risk stratification, diagnosis, prognostication, and treatment. We assessed how TB-IRIS status and dexamethasone influence leukocyte proteomic responses to Mycobacterium tuberculosis (Mtb). Patient blood was obtained three weeks post-anti-retroviral therapy initiation. Isolated mononuclear cells were stimulated ex vivo with heat-killed Mtb in the presence/absence of dexamethasone. Mass spectrometry-based proteomic comparison of TB-IRIS and non-IRIS patient-derived cells facilitated generation of hypotheses regarding pathogenesis. Few represented TB-IRIS-group immune-related pathways achieved significant activation, with relative under-utilisation of "inter-cellular interaction" and "Fcγ receptor-mediated phagocytosis" (but a tendency towards apoptosis-related) pathways. Dexamethasone facilitated significant activation of innate-related pathways. Differentially-expressed non-IRIS-group proteins suggest focused and co-ordinated immunological pathways, regardless of dexamethasone status. Findings suggest a relative deficit in TB-IRIS-group responses to and clearance of Mtb antigens, ameliorated by dexamethasone.
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Affiliation(s)
- Liam Bell
- Department of Integrative Biomedical Sciences & Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, South Africa; Centre for Proteomic and Genomic Research (CPGR), Observatory, 7925 Cape Town, South Africa
| | - Janique M Peyper
- Department of Integrative Biomedical Sciences & Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, South Africa
| | - Shaun Garnett
- Department of Integrative Biomedical Sciences & Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, South Africa
| | - Rabecca Tadokera
- Department of Integrative Biomedical Sciences & Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, South Africa; Clinical Infectious Diseases Research Initiative, IDM, University of Cape Town, Observatory, 7925 South Africa; HIV/AIDS, STIs and TB Programme, Human Sciences Research Council, Arcadia, 0002 Pretoria, South Africa
| | - Robert Wilkinson
- Department of Medicine, Imperial College, London W2 1PG, UK; Clinical Infectious Diseases Research Initiative, IDM, University of Cape Town, Observatory, 7925 South Africa; Department of Medicine, University of Cape Town, Observatory, 7925 South Africa; Francis Crick Institute, Mill Hill Laboratory, London NW7 1AA, UK
| | - Graeme Meintjes
- Clinical Infectious Diseases Research Initiative, IDM, University of Cape Town, Observatory, 7925 South Africa; Department of Medicine, University of Cape Town, Observatory, 7925 South Africa
| | - Jonathan M Blackburn
- Department of Integrative Biomedical Sciences & Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, South Africa.
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Lyra MR, Nascimento MLFO, Varon AG, Pimentel MIF, Antonio LDF, Saheki MN, Bedoya-Pacheco SJ, Valle ACFD. Immune reconstitution inflammatory syndrome in HIV and sporotrichosis coinfection: report of two cases and review of the literature. Rev Soc Bras Med Trop 2015; 47:806-9. [PMID: 25626666 DOI: 10.1590/0037-8682-0146-2014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 10/14/2014] [Indexed: 11/21/2022] Open
Abstract
We report 2 cases of patients with immune reconstitution inflammatory syndrome (IRIS) associated with cutaneous disseminated sporotrichosis and human immunodeficiency virus (HIV) coinfection. The patients received specific treatment for sporotrichosis. However, after 4 and 5 weeks from the beginning of antiretroviral therapy, both patients experienced clinical exacerbation of skin lesions despite increased T CD4+ cells (T cells cluster of differentiation 4 positive) count and decreased viral load. Despite this exacerbation, subsequent mycological examination after systemic corticosteroid administration did not reveal fungal growth. Accordingly, they were diagnosed with IRIS. However, the sudden withdrawal of the corticosteroids resulted in the recurrence of IRIS symptoms. No serious adverse effects could be attributed to prednisone. We recommend corticosteroid treatment for mild-to-moderate cases of IRIS in sporotrichosis and HIV coinfection with close follow-up.
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Affiliation(s)
- Marcelo Rosandiski Lyra
- Laboratório de Vigilância em Leishmanioses, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brasil
| | | | - Andréa Gina Varon
- Laboratório de Micobactéria, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brasil
| | - Maria Inês Fernandes Pimentel
- Laboratório de Vigilância em Leishmanioses, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brasil
| | - Liliane de Fátima Antonio
- Laboratório de Vigilância em Leishmanioses, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brasil
| | - Maurício Naoto Saheki
- Laboratório de Vigilância em Leishmanioses, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brasil
| | - Sandro Javier Bedoya-Pacheco
- Laboratório de Vigilância em Leishmanioses, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brasil
| | - Antonio Carlos Francesconi do Valle
- Laboratório de Vigilância em Leishmanioses, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brasil
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Meintjes G, Boulle A. Immune reconstitution inflammatory syndrome in a large multicenter cohort study: case definition and comparability. Expert Rev Anti Infect Ther 2014; 10:737-41. [PMID: 22943397 DOI: 10.1586/eri.12.62] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This study was nested within the HIV Outpatient Study cohort and investigated the incidence and risk factors for immune reconstitution inflammatory syndrome (IRIS) and the impact of IRIS on mortality. IRIS was defined as a new type B or C AIDS-defining condition or one of a range of mucocutaneous or autoimmune conditions diagnosed within 180 days of starting a new combination antiretroviral therapy regimen, provided there was a documented HIV viral load or CD4 response. IRIS occurred in 10.6% of the 2610 patients. Risk factors independently associated with IRIS included high HIV viral load and low CD4 count. IRIS related to type B or C AIDS-defining conditions was associated with subsequent mortality. Deaths among IRIS cases occurred over 3 years (median) after the IRIS event, making it unlikely that these deaths were directly attributable to IRIS. The IRIS case definition used has important differences when compared with previously published IRIS case definitions thereby affecting comparability of these findings, but this was a pragmatic definition for a large multicenter cohort study utilizing a central database.
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Affiliation(s)
- Graeme Meintjes
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, Western Cape, South Africa.
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Espinosa E, Romero-Rodríguez DP, Cantoral-Díaz MT, Reyes-Terán G. Transient expansion of activated CD8(+) T cells characterizes tuberculosis-associated immune reconstitution inflammatory syndrome in patients with HIV: a case control study. JOURNAL OF INFLAMMATION-LONDON 2013; 10:21. [PMID: 23688318 PMCID: PMC3679878 DOI: 10.1186/1476-9255-10-21] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Accepted: 05/13/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND CD4(+) T cell activation indicators have been reported to be a common phenomenon underlying diverse manifestations of immune reconstitution inflammatory syndrome (IRIS). However, we have found that a high frequency of circulating CD8(+) T cells is a specific risk factor for mycobacterial IRIS. Therefore, we investigated whether CD8(+) T cells from patients who develop TB IRIS were specifically activated. METHODS We obtained PBMCs from HIV+ patients prior to and 4, 8, 12, 24, 52 and 104 weeks after initiating antiretroviral therapy. CD38 and HLADR expression on naive, central memory and effector memory CD8(+) and CD4(+) T cells were determined by flow cytometry. Absolute counts and frequencies of CD8(+) T cell subsets were compared between patients who developed TB IRIS, who developed other IRIS forms and who remained IRIS-free. RESULTS TB IRIS patients showed significantly higher counts of naive CD8(+) T cells than the other groups at most time points, with a contraction of the effector memory subpopulation occurring later in the follow-up period. Activated (CD38(+) HLADR(+)) CD8(+) T cells from all groups decreased with treatment but transiently peaked in TB IRIS patients. This increase was due to an increase in activated naive CD8(+) T cell counts during IRIS. Additionally, the CD8(+) T cell subpopulations of TB IRIS patients expressed HLADR without CD38 more frequently and expressed CD38 without HLADR less frequently than cells from other groups. CONCLUSIONS CD8(+) T cell activation is specifically relevant to TB IRIS. Different IRIS forms may involve different alterations in T cell subsets, suggesting different underlying inflammatory processes.
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Affiliation(s)
- Enrique Espinosa
- Center for Infectious Diseases Research (CIENI), Instituto Nacional de Enfermedades Respiratorias "Ismael Cosío Villegas", Calzada de Tlalpan 4502, 14080 México, D.F.Mexico.,Present address: Laboratorio de Inmunobiología y Genética, Instituto Nacional de Enfermedades Respiratorias "Ismael Cosío Villegas", Calzada de Tlalpan 4502, 14080 México, D.F.Mexico
| | - Dámaris P Romero-Rodríguez
- Center for Infectious Diseases Research (CIENI), Instituto Nacional de Enfermedades Respiratorias "Ismael Cosío Villegas", Calzada de Tlalpan 4502, 14080 México, D.F.Mexico.,Present address: Laboratorio de Inmunobiología y Genética, Instituto Nacional de Enfermedades Respiratorias "Ismael Cosío Villegas", Calzada de Tlalpan 4502, 14080 México, D.F.Mexico
| | - María-Teresa Cantoral-Díaz
- Center for Infectious Diseases Research (CIENI), Instituto Nacional de Enfermedades Respiratorias "Ismael Cosío Villegas", Calzada de Tlalpan 4502, 14080 México, D.F.Mexico
| | - Gustavo Reyes-Terán
- Center for Infectious Diseases Research (CIENI), Instituto Nacional de Enfermedades Respiratorias "Ismael Cosío Villegas", Calzada de Tlalpan 4502, 14080 México, D.F.Mexico
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HIV: practical implications for the practicing allergist-immunologist. Ann Allergy Asthma Immunol 2011; 107:1-9; quiz 9-11. [PMID: 21704878 DOI: 10.1016/j.anai.2011.05.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Revised: 04/14/2011] [Accepted: 05/02/2011] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To review the effects of human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) on allergic diseases and discuss the clinical, pathophysiologic, diagnostic, and therapeutic challenges unique to HIV-infected patients receiving highly active antiretroviral therapy (HAART). DATA SOURCES The MEDLINE and OVID databases were searched to identify pertinent articles using the following keywords: HIV, AIDS, IgE, allergic rhinitis, adverse drug reaction, asthma, chronic obstructive pulmonary disease, food allergy, and immunization. References from the chosen articles were also examined. STUDY SELECTION Articles were selected based on their relevance to the subject matter and currency. RESULTS Human immunodeficiency virus infection causes immunologic alterations that ultimately lead to cell-mediated immune deficiency. In addition, the immune dysfunction caused by HIV also increases the likelihood of developing allergic and other immune-mediated diseases in many patients. HAART is associated with reconstitution of immune system function. While offering protection against infection, immune reconstitution also can provoke immunopathologic conditions. Patients infected with HIV show an increased prevalence of allergic rhinitis, adverse drug reactions, and noninfectious pulmonary complications. The pathophysiology of HIV infection is associated with unique clinical, diagnostic, and therapeutic considerations when treating allergic diseases in HIV-infected patients. CONCLUSIONS With the use of HAART and the subsequent decrease in infectious complications, HIV-infected patients now live longer and experience common chronic diseases. Evaluation of HIV-infected patients with rhinitis, asthma, and adverse drug reactions may become more frequent as HAART continues to extend the life expectancy of patients living with HIV. Understanding the interactions between HIV and these conditions can facilitate a knowledgeable approach to treating an HIV-infected patient.
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Gengiah TN, Gray AL, Naidoo K, Karim QA. Initiating antiretrovirals during tuberculosis treatment: a drug safety review. Expert Opin Drug Saf 2011; 10:559-74. [PMID: 21204737 PMCID: PMC3114264 DOI: 10.1517/14740338.2011.546783] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Integrating HIV and tuberculosis (TB) treatment can reduce mortality substantially. Practical barriers to treatment integration still exist and include safety concerns related to concomitant drug use because of drug interactions and additive toxicities. Altered therapeutic concentrations may influence the chances of treatment success or toxicity. AREAS COVERED The available data on drug-drug interactions between the rifamycin class of anti-mycobacterials and the non-nucleoside reverse transcriptase inhibitor and the protease inhibitor classes of antiretrovirals are discussed with recommendations for integrated use. Additive drug toxicities, the impact of immune reconstitution inflammatory syndrome (IRIS) and the latest data on survival benefits of integrating treatment are elucidated. EXPERT OPINION Deferring treatment of HIV to avoid drug interactions with TB treatment or the occurrence of IRIS is not necessary. In the integrated management of TB-HIV co-infection, rational drug combinations aimed at reducing toxicities while effecting TB cure and suppressing HIV viral load are possible.
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Affiliation(s)
- Tanuja N Gengiah
- University of KwaZulu-Natal, Centre for the AIDS Programme of Research in South Africa, 719 Umbilo Rd, Durban, 4013, South Africa.
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Piggott DA, Karakousis PC. Timing of antiretroviral therapy for HIV in the setting of TB treatment. Clin Dev Immunol 2010; 2011:103917. [PMID: 21234380 PMCID: PMC3017895 DOI: 10.1155/2011/103917] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Revised: 10/06/2010] [Accepted: 10/20/2010] [Indexed: 11/18/2022]
Abstract
The convergent human immunodeficiency virus (HIV) and tuberculosis (TB) pandemics continue to collectively exact significant morbidity and mortality worldwide. Highly active antiretroviral therapy (HAART) has been a critical component in combating the scourge of these two conditions as both a preemptive and therapeutic modality. However, concomitant administration of antiretroviral and antituberculous therapies poses significant challenges, including cumulative drug toxicities, drug-drug interactions, high pill burden, and the immune reconstitution inflammatory syndrome (IRIS), thus complicating the management of coinfected individuals. This paper will review data from recent studies regarding the optimal timing of HAART initiation relative to TB treatment, with the ultimate goal of improving coinfection-related morbidity and mortality while mitigating toxicity resulting from concurrent treatment of both infections.
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Affiliation(s)
- Damani A. Piggott
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, 1550 Orleans Street, Rm 110, Baltimore, MD 21231, USA
| | - Petros C. Karakousis
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, 1550 Orleans Street, Rm 110, Baltimore, MD 21231, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
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Naess H, Glad S, Storstein A, Rinaldo CH, Mørk SJ, Myhr KM, Hirsch H. Progressive multifocal leucoencephalopathy in an immunocompetent patient with favourable outcome. A case report. BMC Neurol 2010; 10:32. [PMID: 20482768 PMCID: PMC2880963 DOI: 10.1186/1471-2377-10-32] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Accepted: 05/18/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To report the clinical course of PML in an apparently immunocompetent patient treated with cidofovir. CASE PRESENTATION A 35-year-old immunocompetent man who developed progressive hemianopsia, aphasia, and limb weakness underwent repeated MRI scans of the brain, spinal fluid analyses, and brain biopsy. Before diagnosis was established based on brain biopsy, he was consecutively treated with methylprednisolone, acyclovir, ceftriaxone and plasmapheresis, but he deteriorated rapidly suggestive of the immune reconstitution inflammatory syndrome (IRIS). He started to recover two weeks after the initiation of treatment with cidofovir and has had no relapse at 3 1/2 years of follow-up. MRI has shown marked improvement. CONCLUSIONS PML should be considered in immunocompetent patients with a typical clinical course and MRI findings compatible with PML. Treatment with cidofovir should be considered as early as possible in the disease course.
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Affiliation(s)
- Halvor Naess
- Department of Neurology, Haukeland University Hospital, N-5021 Bergen, Norway.
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Affiliation(s)
- Martyn A French
- Department of Clinical Immunology and Immunogenetics, Royal Perth Hospital, Perth, Australia.
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