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Wang M, Cui Y, Shi J, Yan J. Difficulty in diagnosing intracranial infection caused by Mycobacterium avium in an AIDS patient: case report and review of the literature. Diagn Pathol 2024; 19:96. [PMID: 38982440 PMCID: PMC11232309 DOI: 10.1186/s13000-024-01515-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 06/20/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND Mycobacterium avium complex (MAC) is an uncommon clinical pathogen, especially in the central nervous system (CNS), and carries a poor prognosis. MAC infections commonly present as immune reconstitution disease (IRD) in HIV patients. Herein, we report a case of intracranial infection caused by MAC in an AIDS patient without disseminated MAC (DMAC) and immune reconstitution inflammatory syndrome (IRIS). CASE PRESENTATION A 31-year-old HIV-positive male presented us with progressively worsening CNS symptoms, and neuroimaging revealed ring-enhancing lesions. The intracranial lesions worsened after the empirical therapy for toxoplasma encephalitis and fungal infection. Due to the rapid progression of the disease, the patient died. Mycobacterium avium was the only pathogen in brain tissue after cultures and molecular biology tests. CONCLUSION MAC infection in CNS is challenging to diagnose in HIV patients. Our findings emphasize that obtaining tissue samples and applying molecular biology methods is essential to help diagnose the patient as soon as possible to receive adequate treatment.
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Affiliation(s)
- Mengyan Wang
- Department II of Infectious Diseases, Xixi Hospital of Hangzhou, Hangzhou Xixi Hospital Affiliated to Zhejiang University of Traditional Chinese Medicine, Hangzhou, China
| | - Yahui Cui
- Department of Neurosurgery, Xixi Hospital of Hangzhou, Hangzhou Xixi Hospital Affiliated to Zhejiang University of Traditional Chinese Medicine, Hangzhou, China
| | - Jinchuan Shi
- Department II of Infectious Diseases, Xixi Hospital of Hangzhou, Hangzhou Xixi Hospital Affiliated to Zhejiang University of Traditional Chinese Medicine, Hangzhou, China
| | - Jun Yan
- Department II of Infectious Diseases, Xixi Hospital of Hangzhou, Hangzhou Xixi Hospital Affiliated to Zhejiang University of Traditional Chinese Medicine, Hangzhou, China.
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2
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Jog A, Schmidt P, Hallal PL, Novitch R. Chylothorax: A Late Complication of Disseminated Mycobacterium avium Complex (MAC) Infection. Cureus 2023; 15:e40347. [PMID: 37456383 PMCID: PMC10339148 DOI: 10.7759/cureus.40347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 07/18/2023] Open
Abstract
Chylothorax is a rare cause of pleural effusion and occurs due to leakage of chyle into the pleural space. In most cases, it results from trauma, with malignancy accounting for most of the non-traumatic causes. Chylothorax resulting from immune reconstitution inflammatory syndrome (IRIS), during treatment of Mycobacterium avium complex (MAC) infection, is an extremely infrequent cause of chylothorax, with only a handful of cases reported in the literature.
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Affiliation(s)
- Abhishrut Jog
- Pulmonary Medicine, BronxCare Health System, Bronx, USA
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Xerri T, Borg J, Casha R, Fsadni C. Complexity of Mycobacterium avium complex immune reconstitution inflammatory syndrome (MAC-IRIS) in a patient with HIV. BMJ Case Rep 2021; 14:e241813. [PMID: 34479876 PMCID: PMC8420731 DOI: 10.1136/bcr-2021-241813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2021] [Indexed: 01/08/2023] Open
Abstract
We report a case of Mycobacterium avium complex immune reconstitution inflammatory syndrome (MAC-IRIS) in a patient with HIV positive. Initial presentation was that of a purpuric purple macular rash in-keeping with Kaposi sarcoma as an AIDS defining illness. Three weeks following the initiation of antiretroviral treatment (ART) she developed chest pain, dry cough and fever. A diagnosis of MAC was made through imaging and sputum cultures and appropriate treatment was initiated. Despite adequate management with evidence of good immunological and virological response, the patient represented with persistent symptoms. Repeat CT of the chest confirmed worsening lymphadenopathy with necrosis. Given these findings, a diagnosis of MAC-IRIS was made with resolution of fever after corticosteroids were initiated. This case highlights the importance of considering MAC as a cause of IRIS in severely immunosuppressed patients with HIV.
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Affiliation(s)
- Thelma Xerri
- Infectious Diseases Unit, Mater Dei Hospital, Msida, Malta
| | - Janice Borg
- Department of Medicine, Mater Dei Hospital, Msida, Malta
| | - Ramon Casha
- Infectious Diseases Unit, Mater Dei Hospital, Msida, Malta
| | - Claudia Fsadni
- Infectious Diseases Unit, Mater Dei Hospital, Msida, Malta
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4
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Abstract
Care of patients with human immunodeficiency virus (HIV) infection in the intensive care unit (ICU) has changed dramatically since the infection was first recognized in the United States in 1981. The purpose of this review is to describe the current important aspects of care of patients with HIV infection in the ICU, with a primary focus on the United States and developed countries. The epidemiology and initial approach to diagnosis and treatment of HIV (including the newest antiretroviral guidelines), common syndromes and their management in the ICU, and typical comorbidities and opportunistic infections of patients with HIV infection are discussed.
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Lee YC, Chiou CC, Wang JT, Yang YC, Tung SH, Hsieh SM. Non-traumatic perforation of the jejunum in a human immunodeficiency virus-infected patient receiving combination antiretroviral therapy: A case report. Medicine (Baltimore) 2019; 98:e18163. [PMID: 31804330 PMCID: PMC6919416 DOI: 10.1097/md.0000000000018163] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
RATIONALE Non-traumatic bowel perforation caused by cytomegalovirus (CMV) and Mycobacterium avium complex (MAC) infections has become rare among patients with acquired immunodeficiency syndrome (AIDS) in the era of combination antiretroviral therapy (cART); however, CMV-associated and MAC-related immune reconstitution inflammatory syndrome (IRIS) has subsequently emerged owing to the wide use of integrase inhibitor-based regimens. Here we report a case of spontaneous perforation of the jejunum in a patient with human immunodeficiency virus (HIV) infection with good compliance to cART. PATIENT CONCERNS A 32-year-old HIV-infected man developed CMV disease and DMAC infection, as unmasking IRIS, 3 days after the initiation of cART. After appropriate treatment for opportunistic infections, intermittent fever with enlarged lymph nodes in the abdomen occurred as paradoxical IRIS. The patient was administered prednisolone with subsequent tapering according to his clinical condition. DIAGNOSES Unexpected perforation of hollow organ during the titration of steroid dose with clinical presentations of severe abdominal pain was diagnosed by chest radiography. INTERVENTIONS He underwent surgical repair with peritoneal toileting smoothly. OUTCOMES He was discharged well with a clean surgical wound on post-operative day 10. LESSONS Bowel perforation may be a life-threatening manifestation of IRIS in the era of cART. Steroids should be avoided, if possible, to decrease the risk of bowel perforation, especially in IRIS occurred after opportunistic diseases involving the gastrointestinal tract.
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Affiliation(s)
- Yi-Chien Lee
- Department of Internal Medicine, Fu Jen Catholic University Hospital
- School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City
| | - Chien-Chun Chiou
- Department of Dermatology, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi
| | - Jann-Tay Wang
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
- Institute for Infectious Diseases and Vaccinology, National Health Research Institutes
| | - Yi-Chun Yang
- Department of Nursing, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Shao-Hsien Tung
- Department of Internal Medicine, Fu Jen Catholic University Hospital
| | - Szu-Min Hsieh
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
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6
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Large abscess formed in the abdominal wall by Mycobacterium avium complex: A case of unmasking immune reconstitution inflammatory syndrome. IDCases 2019; 18:e00609. [PMID: 31428560 PMCID: PMC6695246 DOI: 10.1016/j.idcr.2019.e00609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 07/23/2019] [Accepted: 07/23/2019] [Indexed: 11/20/2022] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) is a clinical entity with a broad presentation that is complicated in patients with acquired immunodeficiency syndrome after initiating antiretroviral therapy. A 51-year-old Japanese man was diagnosed with disseminated Mycobacterium avium complex (MAC) infection presenting as unmasking IRIS, which formed a large abscess in the patient's abdominal wall. MAC-IRIS commonly involves the lymph nodes, bone marrow, and gastrointestinal tract. To our knowledge, this is the first case report of an abdominal wall abscess caused by MAC-IRIS.
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7
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Smibert OC, Trubiano JA, Cross GB, Hoy JF. Short Communication: Mycobacterium avium Complex Infection and Immune Reconstitution Inflammatory Syndrome Remain a Challenge in the Era of Effective Antiretroviral Therapy. AIDS Res Hum Retroviruses 2017; 33:1202-1204. [PMID: 28791872 DOI: 10.1089/aid.2017.0030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A 10-year review of disseminated Mycobacterium avium complex (MAC) infection and MAC-immune reconstitution inflammatory syndrome in HIV-positive patients (2004-2014) at a state-wide tertiary referral HIV service demonstrates that despite advances in antiretroviral therapy, MAC infection remains a therapeutic challenge, particularly intra-abdominal disease.
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Affiliation(s)
- Olivia C. Smibert
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Jason A. Trubiano
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Gail B. Cross
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Jennifer F. Hoy
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
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8
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Abstract
In HIV-infected individuals, paradoxical reactions after the initiation of antiretroviral therapy (ART) are associated with a variety of underlying infections and have been called the immune reconstitution inflammatory syndrome (IRIS). In cases of IRIS associated with tuberculosis (TB), two distinct patterns of disease are recognized: (i) the progression of subclinical TB to clinical disease after the initiation of ART, referred to as unmasking, and (ii) the progression or appearance of new clinical and/or radiographic disease in patients with previously recognized TB after the initiation of ART, the classic or "paradoxical" TB-IRIS. IRIS can potentially occur in all granulomatous diseases, not just infectious ones. All granulomatous diseases are thought to result from interplay of inflammatory cells and mediators. One of the inflammatory cells thought to be integral to the development of the granuloma is the CD4 T lymphocyte. Therefore, HIV-infected patients with noninfectious granulomatous diseases such as sarcoidosis may also develop IRIS reactions. Here, we describe IRIS in HIV-infected patients with TB and sarcoidosis and review the basic clinical and immunological aspects of these phenomena.
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9
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Abstract
Despite the ubiqitous nature of Mycobacterium avium complex (MAC) organisms in the environment, relatively few of those who are infected develop disease. Thus, some degree of susceptibility due to either underlying lung disease or immunosuppression is required. The frequency of pulmonary MAC disease is increasing in many areas, and the exact reasons are unknown. Isolation of MAC from a respiratory specimen does not necessarily mean that treatment is required, as the decision to treatment requires the synthesis of clinical, radiographic, and microbiologic information as well as a weighing of the risks and benefits for the individual patient. Successful treatment requires a multipronged approach that includes antibiotics, aggressive pulmonary hygiene, and sometimes resection of the diseased lung. A combination of azithromycin, rifampin, and ethambutol administered three times weekly is recommend for nodular bronchiectatic disease, whereas the same regimen may be used for cavitary disease but administered daily and often with inclusion of a parenteral aminoglycoside. Disseminated MAC (DMAC) is almost exclusively seen in patients with late-stage AIDS and can be treated with a macrolide in combination with ethambutol, with or without rifabutin: the most important intervention in this setting is to gain HIV control with the use of potent antiretroviral therapy. Treatment outcomes for many patients with MAC disease remain suboptimal, so new drugs and treatment regimens are greatly needed. Given the high rate of reinfection after cure, one of the greatest needs is a better understanding of where infection occurs and how this can be prevented.
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10
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Bana TM, Lesosky M, Pepper DJ, van der Plas H, Schutz C, Goliath R, Morroni C, Mendelson M, Maartens G, Wilkinson RJ, Meintjes G. Prolonged tuberculosis-associated immune reconstitution inflammatory syndrome: characteristics and risk factors. BMC Infect Dis 2016; 16:518. [PMID: 27677424 PMCID: PMC5039896 DOI: 10.1186/s12879-016-1850-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 09/17/2016] [Indexed: 11/10/2022] Open
Abstract
Background In a proportion of patients with HIV-associated tuberculosis who develop paradoxical immune reconstitution inflammatory syndrome (IRIS), the clinical course of IRIS is prolonged necessitating substantial health care utilization for diagnostic and therapeutic interventions. Prolonged TB-IRIS has not been prospectively studied to date. We aimed to determine the proportion of patients with prolonged TB-IRIS, as well as the clinical characteristics and risk factors for prolonged TB-IRIS. Methods We pooled data from two prospective observational studies and a randomized controlled trial conducted in Cape Town, South Africa, that enrolled patients with paradoxical TB-IRIS. We used the same diagnostic approach and clinical case definitions for TB-IRIS in the 3 studies. Prolonged TB-IRIS was defined as TB-IRIS symptoms lasting > 90 days. Risk factors for prolonged TB-IRIS were analysed using Wilcoxon rank sum test, Fisher’s exact test, multivariate logistic regression and Cox proportional hazards models. Results Two-hundred and sixteen patients with TB-IRIS were included. The median duration of TB-IRIS symptoms was 71.0 days (IQR 41.0–113.2). In 73/181 patients (40.3 %) with adequate follow-up data, IRIS duration was > 90 days. Six patients (3.3 %), mainly with lymph node involvement, had IRIS duration > 1 year. In univariate logistic regression analysis the following were significantly associated with IRIS duration > 90 days: lymph node involvement at initial TB diagnosis, drug-resistant TB, lymph node TB-IRIS, and not being hospitalised at time of TB-IRIS diagnosis. In our multivariate logistic regression model lymph node TB-IRIS (aOR 2.27, 95 % CI 1.13–4.59) and not being hospitalised at time of TB-IRIS diagnosis (aOR for being hospitalised 0.5, 95 % CI 0.25-0.99) remained significantly associated with prolonged TB-IRIS, and drug-resistant TB was of borderline significance (aOR 3.26, 95 % CI 0.97–12.99). The association of not being hospitalised with longer duration of IRIS might be related to 1 of the 3 cohorts in which all patients were hospitalised at ART initiation with close inpatient follow-up. This could have resulted in diagnosis of milder cases and earlier IRIS treatment potentially resulting in shorter TB-IRIS duration in these hospitalised patients. Conclusions Around 40 % of patients with TB-IRIS have symptoms for more than 90 days. Involvement of lymph nodes at time of TB-IRIS is an independent risk factor for prolonged TB-IRIS. Future studies should address whether more prompt anti-inflammatory treatment of lymph node TB-IRIS reduces the risk of prolonged TB-IRIS. Trial registration The randomized controlled trial was registered with Current Controlled Trials ISRCTN21322548 on 17 August 2005. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1850-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tasnim M Bana
- Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Maia Lesosky
- Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Dominique J Pepper
- Critical Care Medicine Department, National Institutes of Health, Bethesda, MD, USA
| | - Helen van der Plas
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Charlotte Schutz
- Department of Medicine, University of Cape Town, Observatory, 7925, South Africa.,Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, 7925, South Africa
| | - Rene Goliath
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, 7925, South Africa
| | - Chelsea Morroni
- Institute for Women's Health and Institute for Global Health, University College London, London, UK
| | - Marc Mendelson
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Robert J Wilkinson
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa.,Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, 7925, South Africa.,Francis Crick Institute, London, NW7 1AA, UK.,Department of Medicine, Imperial College London, London, W2 1PG, UK
| | - Graeme Meintjes
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa. .,Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, 7925, South Africa. .,Department of Medicine, Imperial College London, London, W2 1PG, UK.
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Naidoo S, Louis Naicker V. Retrospective comparison of cytological and histological bone marrow morphology in adult antiretroviral-naïve and antiretroviral experienced human immunodeficiency virus-infected patients with peripheral blood cytopaenias. S Afr J Infect Dis 2016. [DOI: 10.1080/23120053.2016.1128147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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12
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Corti M, Palmero D. Mycobacterium aviumcomplex infection in HIV/AIDS patients. Expert Rev Anti Infect Ther 2014; 6:351-63. [PMID: 18588499 DOI: 10.1586/14787210.6.3.351] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Marcelo Corti
- HIV/AIDS Division, Infectious Diseases FJ Muñiz Hospital, Buenos Aires, Argentina.
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13
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Thoden J, Potthoff A, Bogner JR, Brockmeyer NH, Esser S, Grabmeier-Pfistershammer K, Haas B, Hahn K, Härter G, Hartmann M, Herzmann C, Hutterer J, Jordan AR, Lange C, Mauss S, Meyer-Olson D, Mosthaf F, Oette M, Reuter S, Rieger A, Rosenkranz T, Ruhnke M, Schaaf B, Schwarze S, Stellbrink HJ, Stocker H, Stoehr A, Stoll M, Träder C, Vogel M, Wagner D, Wyen C, Hoffmann C. Therapy and prophylaxis of opportunistic infections in HIV-infected patients: a guideline by the German and Austrian AIDS societies (DAIG/ÖAG) (AWMF 055/066). Infection 2013; 41 Suppl 2:S91-115. [PMID: 24037688 PMCID: PMC3776256 DOI: 10.1007/s15010-013-0504-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 06/28/2013] [Indexed: 11/24/2022]
Abstract
INTRODUCTION There was a growing need for practical guidelines for the most common OIs in Germany and Austria under consideration of the local epidemiological conditions. MATERIALS AND METHODS The German and Austrian AIDS societies developed these guidelines between March 2010 and November 2011. A structured Medline research was performed for 12 diseases, namely Immune reconstitution inflammatory syndrome, Pneumocystis jiroveci pneumonia, cerebral toxoplasmosis, cytomegalovirus manifestations, candidiasis, herpes simplex virus infections, varizella zoster virus infections, progressive multifocal leucencephalopathy, cryptosporidiosis, cryptococcosis, nontuberculosis mycobacteria infections and tuberculosis. Due to the lack of evidence by randomized controlled trials, part of the guidelines reflects expert opinions. The German version was accepted by the German and Austrian AIDS Societies and was previously published by the Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF; German Association of the Scientific Medical Societies). CONCLUSION The review presented here is a translation of a short version of the German-Austrian Guidelines of opportunistic infections in HIV patients. These guidelines are well-accepted in a clinical setting in both Germany and Austria. They lead to a similar treatment of a heterogeneous group of patients in these countries.
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Affiliation(s)
- J Thoden
- Private Practice Dr. C. Scholz and Dr. J. Thoden, Bertoldstrasse 8, 79098, Freiburg, Germany,
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Mycobacterium avium complex infection-related immune reconstitution inflammatory syndrome of the central nervous system in an HIV-infected patient: Case report and review. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2013; 46:68-72. [DOI: 10.1016/j.jmii.2011.12.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Revised: 11/30/2011] [Accepted: 12/12/2011] [Indexed: 11/19/2022]
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Armstrong WS. The immune reconstitution inflammatory syndrome: a clinical update. Curr Infect Dis Rep 2013; 15:39-45. [PMID: 23224580 DOI: 10.1007/s11908-012-0308-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The immune reconstitution inflammatory syndrome (IRIS) is a well-described phenomenon in HIV-infected patients following initiation of antiretroviral therapy and can lead to significant morbidity and mortality in some patients. Risk for IRIS is enhanced in those with low CD4 counts and preexisting opportunistic infections. The development of pathogen-specific definitions of IRIS has aided classification of patients and has facilitated research. Newer data on optimal timing of ART initiation, with additional data in the setting of tuberculosis and cryptococcal meningitis, will help guide strategies to decrease the risk of IRIS but must balance the risks of HIV disease progression. Managing patients with IRIS can be challenging. Treatment options include pathogen-specific therapy, antiinflammatory therapies, and other novel approaches.
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Affiliation(s)
- Wendy S Armstrong
- Division of Infectious Disease, Emory University School of Medicine, 341 Ponce de Leon Ave, Atlanta, GA, 30308, USA,
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16
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Meintjes G, Scriven J, Marais S. Management of the immune reconstitution inflammatory syndrome. Curr HIV/AIDS Rep 2012; 9:238-50. [PMID: 22752438 DOI: 10.1007/s11904-012-0129-5] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The immune reconstitution inflammatory syndrome (IRIS) is a frequent early complication of antiretroviral therapy (ART) in patients with advanced HIV. Because there is no confirmatory diagnostic test, the diagnosis is based on clinical presentation and exclusion of alternative causes for deterioration, such as antimicrobial drug resistance. Opportunistic infection treatment should be optimized. Mild cases may require symptomatic therapy alone or nonsteroidal anti-inflammatory drugs. Corticosteroids have been used to treat more severe cases of IRIS associated with mycobacterial and fungal infections. There is evidence from a randomized controlled trial that prednisone reduces morbidity and improves symptoms in paradoxical tuberculosis (TB)-IRIS. Neurological TB-IRIS is potentially life-threatening; high-dose corticosteroids are indicated and ART interruption should be considered if level of consciousness is depressed. When considering corticosteroid treatment clinicians should be aware of their side effects and only use them when the diagnosis of IRIS is certain. In viral forms of IRIS corticosteroids are generally avoided.
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Affiliation(s)
- Graeme Meintjes
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
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17
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Bussone G, Brossier F, Roudiere L, Bille E, Sekkal N, Charlier C, Gilquin J, Lanternier F, Lecuit M, Lortholary O, Catherinot E. Recurrent Mycobacterium avium infection after seven years of latency in a HIV-infected patient receiving efficient antiretroviral therapy. J Infect 2012; 64:613-7. [PMID: 22230736 DOI: 10.1016/j.jinf.2011.12.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Revised: 12/18/2011] [Accepted: 12/29/2011] [Indexed: 11/29/2022]
Abstract
We report the first case of Mycobacterium avium reactivation, after prolonged latency, in a HIV-infected patient receiving highly active antiretroviral therapy with undetectable viral replication and normal CD4 cell count. The patient presented with a painful swollen shoulder seven years after initial M. avium bacteriaemia. Articular puncture grew M. avium. The isolates of the first and second infection were identical using repetitive-sequence-based Polymerase Chain Reaction analyses.
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Affiliation(s)
- Guillaume Bussone
- Université Paris Descartes, Service de Maladies Infectieuses et Tropicales, Centre d'Infectiologie Necker-Pasteur, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
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18
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Lin RJ, Song J. An unusual cause of chest pain: Mycobacterium avium complex and the immune reconstitution inflammatory syndrome. J Hosp Med 2011; 6:309-11. [PMID: 20652963 DOI: 10.1002/jhm.676] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2009] [Revised: 01/26/2010] [Accepted: 01/26/2010] [Indexed: 11/07/2022]
Abstract
The HIV-associated immune reconstitution inflammatory syndrome usually manifests as new infections or worsening of pre-existing infections during the first few months of initiating anti-retroviral therapy. It is commonly associated with local or systemic inflammation, presumably due to rapid reconstitution of host immune system. Here we describe a unique case of the immune reconstitution inflammatory syndrome presenting as acute pericarditis and pericardial effusion caused by mycobacterium avium complex. We also demonstrate that judicious use of steroids, along with pathogen specific antimicrobial therapy, can prevent local complications of the inflammatory response.
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Affiliation(s)
- Richard J Lin
- Department of Medicine, Weill Cornell Medical Center, New York, New York, USA.
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19
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Babiker ZOE, Beeston C, Purcell J, Desai N, Ustianowski A. Mycobacterium avium complex suppurative parotitis in a patient with human immunodeficiency virus infection presenting with immune reconstitution inflammatory syndrome. J Med Microbiol 2010; 59:1365-1367. [PMID: 20634331 DOI: 10.1099/jmm.0.022095-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Restoration of the immune system following initiation of antiretroviral therapy can result in an adverse phenomenon known as immune reconstitution inflammatory syndrome (IRIS). Herein, we report a case of Mycobacterium avium complex (MAC) suppurative parotitis associated with IRIS in a patient with advanced human immunodeficiency virus disease. To the best of our knowledge, this is the first reported case of MAC parotitis in the setting of IRIS and clinicians should be aware of this condition.
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Affiliation(s)
- Zahir Osman Eltahir Babiker
- Department of Infectious Diseases & Tropical Medicine, North Manchester General Hospital, Delaunays Road, Manchester M8 5RB, UK
| | - Christine Beeston
- Department of Infectious Diseases & Tropical Medicine, North Manchester General Hospital, Delaunays Road, Manchester M8 5RB, UK
| | - Janet Purcell
- Microbiology Department, North Manchester General Hospital, Delaunays Road, Manchester M8 5RB, UK
| | - Niranjan Desai
- Radiology Department, North Manchester General Hospital, Delaunays Road, Manchester M8 5RB, UK
| | - Andrew Ustianowski
- Department of Infectious Diseases & Tropical Medicine, North Manchester General Hospital, Delaunays Road, Manchester M8 5RB, UK
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Immunopathogenesis of immune reconstitution disease in HIV patients responding to antiretroviral therapy. Curr Opin HIV AIDS 2009; 3:419-24. [PMID: 19373000 DOI: 10.1097/coh.0b013e328302ebbb] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The aim of this article is to review the most recent literature regarding the immunopathogenesis of pathogen-associated immune reconstitution disease and to discuss the role of immune activation and various effector molecules and cells such as macrophages, effector and regulatory T cells, and natural killer cells in immune reconstitution disease. RECENT FINDINGS Many HIV patients receiving antiretroviral treatment develop immune reconstitution disease, which is characterized by exaggerated inflammatory immune responses to replicating or dead pathogens. In the majority of these cases, immune reconstitution disease is associated with restoration of pathogen-specific cellular immune responses involving CD4 or CD8 effector T cells. The precise conditions that trigger immune reconstitution disease have not yet been identified. Immune reconstitution disease patients have overt immune activation, which may be due to poor homeostatic control after the fast initial immune recovery in patients receiving antiretroviral therapy. Poor homeostatic control in immune reconstitution disease patients may be linked to unbalanced restoration of effector and regulatory T cells. SUMMARY Although the precise mechanism of immune reconstitution disease is not well understood, it is probably related to rapid restoration of pathogen-specific immune responses and poor homeostatic control that promote exaggerated immunopathological responses, especially if viable pathogens or pathogen debris are present at high concentrations.
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Abstract
PURPOSE OF REVIEW We review immune reconstitution disease associated with mycobacterial infections in patients receiving antiretroviral treatment. We draw particular attention to data relevant to resource-limited settings and focus predominantly on publications over the past year. RECENT FINDINGS Worldwide mycobacteria are the most important group of pathogens associated with immune reconstitution disease. In cohorts of patients with tuberculosis in high-income countries, up to one-third develop immune reconstitution disease compared with only 8-13% in current reports from resource-limited settings. We speculate on potential explanations for this difference. While most cases of tuberculosis immune reconstitution disease are self-limiting, deaths have been reported in South African and Thai cohorts. We discuss how risk and outcomes of tuberculosis immune reconstitution disease represent key variables regarding the optimum time to initiate antiretroviral treatment in tuberculosis patients. A new conceptual framework has been proposed regarding 'unmasking' of tuberculosis during antiretroviral treatment. Increasing numbers of cases of leprosy immune reconstitution disease and Bacillus Calmette-Guérin immune reconstitution disease have also been reported, mainly from resource-limited settings. Immune reconstitution disease associated with a variety of mycobacteria (tuberculous and nontuberculous) was common in a cohort of Thai children. SUMMARY Immune reconstitution disease associated with a range of mycobacteria constitutes a challenge to delivery of antiretroviral treatment worldwide. Data concerning the pathogenesis and management of all forms of mycobacterial immune reconstitution disease are lacking.
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Marais S, Wilkinson RJ, Pepper DJ, Meintjes G. Management of patients with the immune reconstitution inflammatory syndrome. Curr HIV/AIDS Rep 2009; 6:162-71. [PMID: 19589302 DOI: 10.1007/s11904-009-0022-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
A significant proportion of patients present with the immune reconstitution inflammatory syndrome (IRIS) after commencing antiretroviral therapy (ART). This syndrome is most frequently associated with infective causes. The lack of evidence-based treatment guidelines poses challenges in the management of these patients. Alternative causes for deterioration should be excluded, and optimization of treatment for the underlying opportunistic infection is essential. In addition, anti-inflammatory or immunomodulatory therapy may be considered, particularly in severe cases. Corticosteroids, the only treatment for which clinical trial data exist (for treating paradoxical tuberculosis-associated IRIS), are the treatment most frequently used in IRIS. Limited anecdotal reports of benefit exist for other agents, including NSAIDs, pentoxifylline, montelukast, thalidomide, and hydroxychloroquine. Therapeutic procedures (eg, aspiration of pus collections) play an important role in some patients. Interruption of ART may be considered in life-threatening forms of IRIS.
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Affiliation(s)
- Suzaan Marais
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
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Johnson PT, Horton KM, Fishman EK. Nonvascular mesenteric disease: utility of multidetector CT with 3D volume rendering. Radiographics 2009; 29:721-40. [PMID: 19448112 DOI: 10.1148/rg.293085113] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Creation of isotropic volumes with submillimeter multidetector computed tomography (CT) has expanded interpretative practice to routinely include two-dimensional (2D) and three-dimensional (3D) postprocessing techniques. Currently, 2D multiplanar reformatting, maximum intensity projection, and 3D volume rendering are available on most workstations. Only volume rendering yields a 3D display that depicts all tissue types from any orientation. Utility is not limited to vascular applications, as 3D volume rendering can be used to evaluate neoplastic, infectious, and inflammatory processes that affect the small-bowel mesentery. Specifically, interactive interpretation of multidetector CT data sets with volume rendering can help characterize nonvascular mesenteric disease, elucidate its extent through more comprehensive display, and facilitate the identification of complications.
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Affiliation(s)
- Pamela T Johnson
- Russell H. Morgan Department of Radiology and Radiologic Sciences, Johns Hopkins School of Medicine, 601 N Caroline St, Room 3140D, Baltimore, MD 21287, USA.
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Reyes-Corcho A, Bouza-Jiménez Y. [Human immunodeficiency virus and AIDS-associated immune reconstitution syndrome. State of the art]. Enferm Infecc Microbiol Clin 2009; 28:110-21. [PMID: 19632745 DOI: 10.1016/j.eimc.2009.03.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2008] [Revised: 03/20/2009] [Accepted: 03/27/2009] [Indexed: 01/27/2023]
Abstract
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.
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Affiliation(s)
- Andrés Reyes-Corcho
- Servicio de Enfermedades Infecciosas, Hospital Universitario Dr. Gustavo Aldereguía Lima, Cienfuegos, Cuba
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Wu UI, Chen MY, Hu RH, Hsieh SM, Sheng WH, Lo YC, Hung CC, Chang SC. Peritonitis due to Mycobacterium avium complex in patients with AIDS: report of five cases and review of the literature. Int J Infect Dis 2009; 13:285-90. [PMID: 18955006 DOI: 10.1016/j.ijid.2008.07.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2008] [Revised: 07/08/2008] [Accepted: 07/09/2008] [Indexed: 10/21/2022] Open
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