Progressive symptoms and signs following institution of highly active antiretroviral therapy and subsequent antituberculosis therapy: immune reconstitution syndrome or infection?

Immune restoration Klebsiella lymphadenitis

A subset of HIV-infected patients who receive antiretroviral therapy (ART) develop immune restoration syndrome. A case of immune restoration Klebsiella lymphadenitis is described. Fine needle aspiration cytology remains a useful investigative tool in the post-ART era, particularly in the diagnosis of persistent generalized lymphadenopathy, infection and malignancy of the lymph nodes.

Development of a culturally appropriate health-related quality of life measure for human immunodeficiency virus-infected children in Thailand

AIM

  Develop a reliable and valid self-report health-related quality of life (HRQOL) instrument for human immunodeficiency virus (HIV)-infected children in Thailand.

METHODS

  The Thai Quality of Life for HIV-infected Children instrument, the ThQLHC (an HRQOL measure that uses the Pediatric Quality of Life Inventory as a generic core and a 17-item HIV-targeted scale), was developed and administered cross-sectionally to 292 HIV-infected children in Thailand. The disease-targeted scale included HIV-related symptoms, ability to adhere with their treatment regimens and self-image. The internal consistency reliability (Cronbach's α) and construct validity of the ThQLHC scales were then evaluated.

RESULTS

  Internal consistency reliability coefficients ranged from 0.57 to 0.82, with four of five scales reaching the minimal acceptable level (>0.70). Significant associations were found between poor HRQOL and poor self-rated disease severity, care giver's rated overall quality of life, cluster of differentiation (CD) 4 percent and plasma HIV ribonucleic acid level.

CONCLUSION

  Reliable and valid disease-targeted HRQOL measures for HIV-infected children are essential in the assessment of therapeutic effectiveness. The findings of this cross-sectional survey provide support for the reliability and validity of the ThQLHC as an HRQOL outcome measure for HIV-infected Thai children.

[Human immunodeficiency virus and AIDS-associated immune reconstitution syndrome. State of the art]

Since the arrival of highly active antiretroviral therapy (HAART), immune reconstitution syndrome (IRS) has become an increasingly more frequent complication in patients with human immunodeficiency virus (HIV) infection. This article presents a review of the available evidence on this subject, indexed in MEDLINE-PUBMED, BVS-BIREME, and BioMed Central. The review covers the definition, epidemiology, classification, and diagnostic criteria related to IRS. In addition, the clinical particularities of the most frequent etiologies are described, and a proposal for a therapeutic approach is formulated. The prognosis and future implications of this syndrome in the epidemiology of some infectious illnesses in the HIV-positive population are included. Several unresolved aspects are mentioned, such as those related to the pathophysiology of the condition, use of biomarkers for the diagnosis, and the need for evidence-based therapeutic algorithms to enable standardization of treatment for these patients.

Immune reconstitution syndrome in a patient with AIDS with paradoxically deteriorating brain tuberculoma

A 54-year-old man with an underlying AIDS experienced fever and lethargy. Magnetic resonance imaging (MRI) showed multiple small ring-enhancement lesions over pons, basal ganglion, thalami, and bilateral cerebral hemisphere. Because of the concurrent pulmonary tuberculosis (TB), presumptive diagnosis of tuberculous meningitis and brain tuberculoma was made. The patient's condition clinically improved after a 3-month anti-TB treatment coupled with highly active antiretroviral therapy (HAART), and his CD4-T lymphocyte count was increased from 17 cells/mm(3) (HIV viral load, 294,000 copies per milliliter) to 153 cells/mm(3) (HIV viral load, 5930 copies per milliliter). However, the follow-up MRI disclosed disappearance of some old brain lesions and development of some new ones; some previously identified tuberculoma became smaller in size, while some other enlarger. Of note, ring-enhanced brain lesions were found over the left frontal lobe and left posterior fossa with perifocal edema and hyperintensity in diffusion weighted MRI indicating abscess formation. Steroid was added based on the presumed paradoxical reaction of brain tuberculoma. Complete resolution of brain lesions was found on MRI 9 months later. Tuberculoma should be considered in a patient with AIDS with numerous intracranial lesions if TB involving other site(s) is definitively diagnosed, especially when the patient is receiving prophylactic trimethoprim-sulfamethoxazole and/or serologically negative for toxoplasmosis. Our report demonstrated the peculiar phenomenon of paradoxical reaction of brain tuberculoma during immune reconstitution and strengthens the belief that additional use of steroids for paradoxical reaction of brain tuberculoma is indicated after exclusion of other causes for the progressively enlarging brain lesions.