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Muthuka JK, Nyamai EM, Oluoch K, Maibvise C, Nabaweesi R. Paradoxical and Unmasking HIV Immune Reconstitution Inflammation Syndrome in Antiretroviral-Naïve Pregnant Women: A Prospective Cohort Study. Cureus 2024; 16:e52989. [PMID: 38406047 PMCID: PMC10894621 DOI: 10.7759/cureus.52989] [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: 01/26/2024] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND AND AIMS Following antiretroviral therapy (ART) initiation, HIV-associated immune reconstitution inflammatory syndrome (IRIS), indicated by an array of opportunistic infections, may occur, presenting as either paradoxical, a worsening of a previously treated infection, or unmasking, a flare-up of an underlying, previously undiagnosed infection. The impact of ART as the backbone of HIV treatment and prevention has prolonged the survival of people living with HIV. In pregnancy, benefits have been shown by slowing HIV progression and preventing perinatal transmission; however, there have been risks of adverse reactions with ART, including immune responses to both the fetus and mother. This study sought to estimate the incidence of HIV-IRIS cumulatively and by type either paradoxical or unmasking IRIS, determine the baseline maternal and HIV clinical markers as predictors of, and analyze the log-rank test for survival time to IRIS outcome assessed by relying on an increase in CD4 count and/or a rapid decrease in viral load. METHODS An active records study was conducted between June 2019 and March 2020 among ART-naïve pregnant women attending the antenatal care units (ANCu) at the Kenyatta National and Mbagathi Hospitals, Nairobi, Kenya. Participants were aged between 20 and 49 years and had a confirmed HIV-positive test. To ascertain a true case of IRIS, the diagnosis was adjudicated for accuracy and consistency by an independent review committee. Plasma HIV viral load, CD4 counts, and routine laboratory evaluations (hemoglobin, white blood cell count (WBC)) were performed by each hospital's clinical laboratory. The IRIS incidence was assessed using the International Network for Studies Against HIV-Associated IRIS (INSHI) during the first three months after ART initiation. Multivariate Cox regression with IRIS as the outcome, using the SPSSSurvival package, examined the relationship between baseline maternal characteristics and HIV clinical markers before ART initiation and IRIS, and finally, decision-tree analysis for predicting IRIS was performed. RESULTS From a pool of 532 ART-naïve pregnant women, 133 (25%) developed IRIS, and 97 (72.9%) were in the unmasking category. The accumulated risk of experiencing IRIS symptoms increased from week two (hazard ratio (HR)=0.0287) to week 12 (HR=3.6158). Participants with a maternal BMI (MBMI) of 25-29.9 kg/m2 at baseline were at a higher risk of unmasking IRIS (HR=2.478; P=0.010). The WHO-HIV clinical stages 1 and 2 skewed towards paradoxical IRIS (regression coefficients =-0.111 and -0.276 (P<0.05)), while stage 4 skewed towards unmasking IRIS (regression coefficient=0.047, HR=1.048, P=0.941). A CD4 count > 500 cells/mm^3 skewed towards unmasking IRIS (regression coefficient=0.192, HR=1.211, P=0.416), while RNA-HIV viral loads >50 copies/ml towards paradoxical IRIS (regression coefficient=-0.199, HR=0.820, P=0.360. On decision tree analysis, 85% (P=0.001) of ART-naïve pregnant women with a baseline CD4 count below 500 copies/mm^3 presented with unmasking IRIS. CONCLUSION For ART-naïve pregnant women, unmasking IRIS is the most common type, and an MBMI of 25-29.9 kg/m2, advanced HIV infection, a CD4 count <500 cells/mm^3, and a higher parity at baseline may be clinically useful predictors. The higher proportion of ART-naïve pregnant women experiencing unmasking as compared to paradoxical IRIS supports the need for earlier assessment based on potential predictors.
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Affiliation(s)
- John K Muthuka
- Epidemiology, Public Health, and Biostatistics, Jomo Kenyatta University of Agriculture & Technology, Nairobi, KEN
- Public Health Sciences, Kenya Medical Training College, Nairobi, KEN
| | | | - Kelly Oluoch
- Pharmacy, Kenya Medical Training College, Nairobi, KEN
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Geteneh A, Andualem H, Belay DM, Kiros M, Biset S. Immune reconstitution inflammatory syndrome, a controversial burden in the East African context: a systematic review and meta-analysis. Front Med (Lausanne) 2023; 10:1192086. [PMID: 37636563 PMCID: PMC10450628 DOI: 10.3389/fmed.2023.1192086] [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] [Received: 03/23/2023] [Accepted: 07/18/2023] [Indexed: 08/29/2023] Open
Abstract
Introduction It is well established that starting antiretroviral therapy (ART) increases a patient's life expectancy among HIV-positive individuals. Considering the HIV pandemic, the major concern is initiation of ARTs to the large segment of HIV infected population, not adverse events from immune restoration. The prevalence of HIV-associated immune reconstitution inflammatory syndrome (IRIS) is poorly estimated due to Africa's underdeveloped infrastructure, particularly in Eastern Africa. Therefore, this study compiled data regarding the magnitude and associated factors of IRIS in the context of Eastern Africa. Methods The electronic databases such as Google Scholar, PubMed, Web of Science, and free Google access were searched till 5 June 2021, and the search was lastly updated on 30 June 2022 for studies of interest. The pooled prevalence, and associated factors with a 95% confidence interval were estimated using the random effects model. The I2 and Egger's tests were used for heterogeneity and publication bias assessment, respectively. Results The development of HIV-associated IRIS in Eastern Africa was estimated to be 18.18% (95% CI 13.30-23.06) in the current review. The two most common predictors of IRIS associated with Eastern Africa were the lower pre-ART CD4 T-cell count of 50 cells/μl and the low baseline body mass index level. Therefore, attention should be focused on the early detection and care of HIV-associated IRIS to reduce the morbidity and death caused by IRIS.
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Affiliation(s)
- Alene Geteneh
- Department of Medical Laboratory Science, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Henok Andualem
- Department of Medical Laboratory Science, College of Medicine and Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Demeke Mesfin Belay
- Department of Pediatrics and Child Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Mulugeta Kiros
- Department of Medical Laboratory Science, College of Medicine and Health Sciences, Aksum University, Aksum, Ethiopia
| | - Sirak Biset
- Department of Medical Microbiology, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Liu Y, Hao Y, Xiao J, Wu L, Liang H, Han J, Zhao H. Trends in rates and causes of hospitalization among people living with HIV in the antiretroviral therapy era: A retrospective cohort study in China, 2008-2020. Front Public Health 2022; 10:1000942. [PMID: 36424978 PMCID: PMC9680952 DOI: 10.3389/fpubh.2022.1000942] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 09/20/2022] [Indexed: 11/09/2022] Open
Abstract
Background The introduction of antiretroviral therapy (ART) has resulted in marked reductions in morbidity among people living with HIV (PLWH). Monitoring the hospitalizations of PLWH is important in evaluating the quality of healthcare and forecasting the co-morbidity pattern. We aimed to describe the trends in the rates and causes of hospitalization among PLWH who initiated ART in an HIV-designated hospital in China. Methods PLWH who initiated ART and were hospitalized in Beijing Ditan Hospital from 2008 to 2020 were selected for the study. Hospitalizations were classified based on AIDS-defining events (ADEs), non-AIDS-defining events (nADEs), and other causes. Hospitalization rates were calculated in terms of person-years, with risk factors determined by Poisson regression. The proportion of hospitalization causes at different ART treatment statuses was also evaluated. Results A total of 9,404 patients (94.7% were male patients) were included, contributing to 49,419 person-years. Overall, 1,551 PLWH were hospitalized for 2,667 hospitalization events, among which 60.4% of hospitalizations were due to ADEs, 11.4% were due to nADEs, and 28.2% were due to other causes. Unadjusted hospitalization rates decreased for all causes and all three diagnostic categories with year. After adjusting for the variables that changed substantially over time, ADE-related [IRR, 1.01 (0.96-1.05)] and nADE-related hospitalization rates [IRR, 0.92 (0.84-1.01)] appeared stable. Hospitalization for ADEs constituted an increasing proportion over time (36.3% in 2008-57.4% in 2020), especially in ART-naive inpatients (43.8% in 2008-83.3% in 2020). The proportion of nADE-related hospitalizations remained low (9.0% in 2008-15.4% in 2020). Hospitalization rate was highest for patients treated with ART during the first 6 months after ART initiation (46.2%) when ADEs were still the leading cause of hospitalizations (30.6%). Older age, non-men who have sex with men transmission, late presenters, HIV viral load (VL) > 50 copies/mL, and CD4 counts ≤ 200 cells/μL were associated with a higher hospitalization risk (all P < 0.05). Conclusion Despite some progress, ADEs remain the most common and serious problem among PLWH in China. In order to avoid deteriorating to the stage of needing hospitalization, more work is needed to diagnose and treat HIV infection earlier.
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Affiliation(s)
- Ying Liu
- National Center for Infectious Diseases, Clinical and Research Center of Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yiwei Hao
- Department of Medical Records and Statistics, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Jiang Xiao
- National Center for Infectious Diseases, Clinical and Research Center of Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Liang Wu
- National Center for Infectious Diseases, Clinical and Research Center of Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Hongyuan Liang
- National Center for Infectious Diseases, Clinical and Research Center of Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Junyan Han
- Biomedical Innovation Center, Beijing Shijitan Hospital, Capital Medical University, Beijing, China,*Correspondence: Junyan Han
| | - Hongxin Zhao
- National Center for Infectious Diseases, Clinical and Research Center of Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, China,Hongxin Zhao
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Poizot-Martin I, Brégigeon S, Palich R, Marcelin AG, Valantin MA, Solas C, Veyri M, Spano JP, Makinson A. Immune Reconstitution Inflammatory Syndrome Associated Kaposi Sarcoma. Cancers (Basel) 2022; 14:cancers14040986. [PMID: 35205734 PMCID: PMC8869819 DOI: 10.3390/cancers14040986] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/28/2022] [Accepted: 02/09/2022] [Indexed: 02/01/2023] Open
Abstract
People living with HIV (PLWH) with advanced immunosuppression who initiate antiretroviral therapy (ART) are susceptible to the occurrence of an immune reconstitution inflammatory syndrome (IRIS). Although ART is responsible for AIDS- associated Kaposi sarcoma (KS) improvement and resolution, new onset (unmasking KS-IRIS) or sudden progression of preexisting KS (paradoxical KS-IRIS) can occur after a time delay of between a few days and 6 months after the initiation or resumption of ART, even in patients with a low degree of immunocompromise. KS-IRIS incidence varies from 2.4% to 39%, depending on study design, populations, and geographic regions. Risk factors for developing KS-IRIS include advanced KS tumor stage (T1), pre-treatment HIV viral load >5 log10 copies/mL, detectable pre-treatment plasma-KSHV, and initiation of ART alone without concurrent chemotherapy. Both paradoxical and unmasking KS-IRIS have been associated with significant morbidity and mortality, and thrombocytopenia (<100,000 platelets/mm3 at 12 weeks) has been associated with death. KS-IRIS is not to be considered as ART failure, and an ART regimen must be pursued. Systemic chemotherapy for KS in conjunction with ART is recommended and, in contrast with management of IRIS for other opportunistic infections, glucocorticoids are contra-indicated. Despite our preliminary results, the place of targeted therapies in the prevention or treatment of KS-IRIS needs further assessment.
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Affiliation(s)
- Isabelle Poizot-Martin
- Assistance Publique-Hôpitaux de Marseille (APHM), Inserm, Institut de Recherche pour le Développement (IRD), SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, ISSPAM, APHM Sainte-Marguerite, Service D’immuno-Hématologie Clinique, Aix-Marseille Université, 13009 Marseille, France
- Correspondence: ; Tel.: +33-4-9174-4966 or +33-4-9174-6163; Fax: +33-4-9174-4962
| | - Sylvie Brégigeon
- Assistance Publique-Hôpitaux de Marseille (APHM) Sainte-Marguerite, Service D’immuno-Hématologie Clinique, Aix-Marseille Université, 13009 Marseille, France;
| | - Romain Palich
- Department of Infectious Diseases, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Pierre Louis Epidemiology and Public Health Institute (iPLESP), INSERM U1136, Sorbonne University, 75013 Paris, France; (R.P.); (M.-A.V.)
| | - Anne-Geneviève Marcelin
- INSERM, Institut Pierre Louis d’Epidémiologie et de Santé Publique (iPLESP), AP-HP, Hôpital Pitié Salpêtrière, Service de Virologie, Sorbonne Université, 75013 Paris, France;
| | - Marc-Antoine Valantin
- Department of Infectious Diseases, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Pierre Louis Epidemiology and Public Health Institute (iPLESP), INSERM U1136, Sorbonne University, 75013 Paris, France; (R.P.); (M.-A.V.)
| | - Caroline Solas
- Assistance Publique-Hôpitaux de Marseille (APHM), Hôpital La Timone, Laboratoire de Pharmacocinétique et Toxicologie, INSERM 1207, IRD 190, Unité des Virus Emergents, Aix-Marseille Université, 13005 Marseille, France;
| | - Marianne Veyri
- Department of Medical Oncology, Pitié Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Institut Universitaire de Cancérologie (IUC), CLIP2 Galilée, Pierre Louis Epidemiology and Public Health Institute (iPLESP), INSERM U1136, Sorbonne Université, 75013 Paris, France; (M.V.); (J.-P.S.)
| | - Jean-Philippe Spano
- Department of Medical Oncology, Pitié Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Institut Universitaire de Cancérologie (IUC), CLIP2 Galilée, Pierre Louis Epidemiology and Public Health Institute (iPLESP), INSERM U1136, Sorbonne Université, 75013 Paris, France; (M.V.); (J.-P.S.)
| | - Alain Makinson
- Centre Hospitalier Universitaire de Montpellier, Département des Maladies Infectieuses et Tropicales, INSERM U1175/IRD UMI 233, 34000 Montpellier, France;
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Vinhaes CL, Araujo-Pereira M, Tibúrcio R, Cubillos-Angulo JM, Demitto FO, Akrami KM, Andrade BB. Systemic Inflammation Associated with Immune Reconstitution Inflammatory Syndrome in Persons Living with HIV. Life (Basel) 2021; 11:life11010065. [PMID: 33477581 PMCID: PMC7831327 DOI: 10.3390/life11010065] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/13/2021] [Accepted: 01/14/2021] [Indexed: 12/19/2022] Open
Abstract
Antiretroviral therapy (ART) has represented a major advancement in the care of people living with HIV (PLWHH), resulting in significant reductions in morbidity and mortality through immune reconstitution and attenuation of homeostatic disruption. Importantly, restoration of immune function in PLWH with opportunistic infections occasionally leads to an intense and uncontrolled cytokine storm following ART initiation known as immune reconstitution inflammatory syndrome (IRIS). IRIS occurrence is associated with the severe and rapid clinical deterioration that results in significant morbidity and mortality. Here, we detail the determinants underlying IRIS development in PLWH, compiling the available knowledge in the field to highlight details of the inflammatory responses in IRIS associated with the most commonly reported opportunistic pathogens. This review also highlights gaps in the understanding of IRIS pathogenesis and summarizes therapeutic strategies that have been used for IRIS.
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Affiliation(s)
- Caian L. Vinhaes
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador 40296-710, Brazil; (C.L.V.); (M.A.-P.); (R.T.); (J.M.C.-A.); (K.M.A.)
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador 40210-320, Brazil;
- Bahiana School of Medicine and Public Health, Bahia Foundation for the Development of Sciences, Salvador 40290-000, Brazil
| | - Mariana Araujo-Pereira
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador 40296-710, Brazil; (C.L.V.); (M.A.-P.); (R.T.); (J.M.C.-A.); (K.M.A.)
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador 40210-320, Brazil;
- Faculdade de Medicina, Universidade Federal da Bahia, Salvador 40110-100, Brazil
| | - Rafael Tibúrcio
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador 40296-710, Brazil; (C.L.V.); (M.A.-P.); (R.T.); (J.M.C.-A.); (K.M.A.)
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador 40210-320, Brazil;
- Faculdade de Medicina, Universidade Federal da Bahia, Salvador 40110-100, Brazil
| | - Juan M. Cubillos-Angulo
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador 40296-710, Brazil; (C.L.V.); (M.A.-P.); (R.T.); (J.M.C.-A.); (K.M.A.)
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador 40210-320, Brazil;
- Faculdade de Medicina, Universidade Federal da Bahia, Salvador 40110-100, Brazil
| | - Fernanda O. Demitto
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador 40210-320, Brazil;
| | - Kevan M. Akrami
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador 40296-710, Brazil; (C.L.V.); (M.A.-P.); (R.T.); (J.M.C.-A.); (K.M.A.)
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador 40210-320, Brazil;
- Faculdade de Medicina, Universidade Federal da Bahia, Salvador 40110-100, Brazil
- Divisions of Infectious Diseases and Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California, San Diego, CA 92093, USA
| | - Bruno B. Andrade
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador 40296-710, Brazil; (C.L.V.); (M.A.-P.); (R.T.); (J.M.C.-A.); (K.M.A.)
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador 40210-320, Brazil;
- Bahiana School of Medicine and Public Health, Bahia Foundation for the Development of Sciences, Salvador 40290-000, Brazil
- Faculdade de Medicina, Universidade Federal da Bahia, Salvador 40110-100, Brazil
- Curso de Medicina, Centro Universitário Faculdade de Tecnologia e Ciências (UniFTC), Salvador 41741-590, Brazil
- Correspondence: ; Tel.: +55-71-3176-2264
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Effect of schistosomiasis on the outcome of patients infected with HIV-1 starting antiretroviral therapy in rural Tanzania. PLoS Negl Trop Dis 2018; 12:e0006844. [PMID: 30332404 PMCID: PMC6205655 DOI: 10.1371/journal.pntd.0006844] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 10/29/2018] [Accepted: 09/13/2018] [Indexed: 01/04/2023] Open
Abstract
Background It has been hypothesized that schistosomiasis negatively influences immune reconstitution in people living with HIV starting antiretroviral therapy (ART). In this study, we investigated the effect of schistosomiasis on the course of HIV infection in patients starting ART in a rural part of Tanzania. Methodology Retrospective study including patients prospectively enrolled in a HIV cohort in Ifakara, south-central Tanzania between January 1, 2013 and April 1, 2015. Schistosomal circulating anodic antigen (CAA) was assessed in pre-ART cryopreserved plasma. Regression models were utilized to estimate the effect of CAA positivity on virological and immunological failure and a composite outcome of death/loss to follow-up (LFU). Principal findings At ART-initiation 19.1% (88/461) of patients were CAA-positive. A tendency of higher CD4 increases was seen in CAA-positive patients (+182 cells/μl, interquartile range (IQR), 87–285 cells/μl) compared to CAA-negative patients (+147 cells/μl, IQR, 55–234 cells/μl, p = 0.09) after 10 months of follow-up. After adjustment for baseline risk factors, CAA-positivity showed no association with virological or immunological failure. In CAA-positive patients, 22.7% (20/88) died or were LFU, compared to 29.5% (110/373) of CAA-negative patients (hazard ratio (HR): 0.76, 95% confidence interval (CI), 0.47–1.22, p = 0.25). After adjustment for age, sex, body mass index, educational attainment, WHO-stage, tuberculosis status, and year of ART initiation, CAA-positivity showed a trend of a decreased hazard of death/LFU (HR: 0.58, 95% CI: 0.32–1.05, p = 0.07), while CD4 count at baseline (HR: 0.86, 95% CI: 0.76–1.00, p = 0.02) and MXD (sum of eosinophils, basophils, and monocytes counts) >1,100 cells/μl (HR: 0.56, 95% CI: 0.34–0.93, p = 0.03) were identified as independently protective factors. Conclusions/Significance Schistosomiasis is prevalent in this HIV cohort and may be beneficial for immunological reconstitution, while no effect on virological failure was apparent. A positive effect of schistosomiasis-induced immunomodulation on survival and retention in care needs confirmation in future studies. Infections with HIV and blood flukes (Schistosoma) both exert chronic modulatory effects on the host’s immune system. Coinfections, meaning the host is simultaneously infected with both pathogens, are common in sub-Saharan Africa. In this situation the induced immune modulation of one pathogen may affect the course of the disease induced by the other pathogen. One study showed that coinfection with Schistosoma in people living with HIV who begin antiretroviral therapy (ART) may have deleterious effects on the reconstitution of the HIV-induced immunosuppression. In the current study, we investigated the effect of Schistosoma coinfection on the recovery of the patient’s immune system, on the efficacy of ART to suppress HIV replication, and on a combined endpoint of lost to follow-up or death. We found that schistosomiasis may have beneficial effects on immune reconstitution, while no deleterious effect was detected on HIV-suppressive efficacy of ART. Surprisingly, our data suggest that schistosomiasis-induced immunomodulatory effects might be beneficial for survival and retention in care. Future studies are warranted to confirm these findings. In the era of increasing access to ART in sub-Saharan Africa, the issue of schistosomiasis-HIV coinfection may have major consequences on the outcome of HIV treatment programs.
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Hosseinipour MC, Kang M, Krown SE, Bukuru A, Umbleja T, Martin JN, Orem J, Godfrey C, Hoagland B, Mwelase N, Langat D, Nyirenda M, MacRae J, Borok M, Samaneka W, Moses A, Mngqbisa R, Busakhala N, Martínez-Maza O, Ambinder R, Dittmer DP, Nokta M, Campbell TB. As-Needed Vs Immediate Etoposide Chemotherapy in Combination With Antiretroviral Therapy for Mild-to-Moderate AIDS-Associated Kaposi Sarcoma in Resource-Limited Settings: A5264/AMC-067 Randomized Clinical Trial. Clin Infect Dis 2018; 67:251-260. [PMID: 29365083 PMCID: PMC6030807 DOI: 10.1093/cid/ciy044] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 01/18/2018] [Indexed: 12/13/2022] Open
Abstract
Background Mild-to-moderate AIDS-associated Kaposi sarcoma (KS) often responds to antiretroviral therapy (ART) alone; the role of chemotherapy is unclear. We assessed the impact of immediate vs as-needed oral etoposide (ET) among human immunodeficiency virus (HIV)-infected individuals with mild-to-moderate KS initiating ART. Methods Chemotherapy-naive, HIV type 1-infected adults with mild-to-moderate KS initiating ART in Africa and South America were randomized to ART (tenofovir/emtricitabine/efavirenz) alone (chemotherapy "as-needed" arm) vs ART plus up to 8 cycles of oral ET (immediate arm). Participants with KS progression on ART alone received ET as part of the as-needed strategy. Primary outcome was ordinal as follows: failure, stable, and response at 48 weeks. Secondary outcomes included time to initial KS progression, KS-associated immune reconstitution inflammatory syndrome (KS-IRIS), and KS response. Results Of 190 randomized participants (as-needed = 94, immediate = 96), the majority were men (71%) and African (93%). Failure (53.8% vs 56.6%), stable (16.3% vs 10.8%), and response (30% vs 32.5%) did not differ between arms (as-needed vs immediate) among those with week 48 data potential (N = 163, P = .91). Time to KS progression (P = .021), KS-IRIS (P = .003), and KS response (P = .003) favored the immediate arm. Twenty-five participants died (13%). Mortality, adverse events, CD4+ T-cell changes, and HIV RNA suppression were similar at 48 weeks. Conclusions Among HIV-infected adults with mild-to-moderate KS, immediate ET provided early, nondurable clinical benefits. By 48 weeks, no clinical benefit was observed compared to use of ET as needed. Mortality was high and tumor response was low. Clinical Trials Registration NCT01352117.
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Affiliation(s)
- Mina C Hosseinipour
- UNC Project, Lilongwe, Malawi
- University of North Carolina School of Medicine, Chapel Hill
| | - Minhee Kang
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | | | - Triin Umbleja
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | | | - Catherine Godfrey
- HIV Research Branch, TRP, DAIDS, NIAID, National Institutes of Health, Rockville, Maryland
| | | | | | - Deborah Langat
- Kenya Medical Research Institute/Walter Reed Project, Kericho
| | - Mulinda Nyirenda
- Johns Hopkins Project, University of Malawi College of Medicine, Blantyre, Malawi
| | | | - Margaret Borok
- AIDS Malignancy Consortium, New York, New York
- University of Zimbabwe, Harare
| | | | - Agnes Moses
- UNC Project, Lilongwe, Malawi
- University of North Carolina School of Medicine, Chapel Hill
- AIDS Malignancy Consortium, New York, New York
| | | | | | | | - Richard Ambinder
- AIDS Malignancy Consortium, New York, New York
- Johns Hopkins University, Baltimore
| | - Dirk P Dittmer
- University of North Carolina School of Medicine, Chapel Hill
- AIDS Malignancy Consortium, New York, New York
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Vignesh R, Swathirajan CR, Solomon SS, Shankar EM, Murugavel KG. Risk factors and frequency of tuberculosis-associated immune reconstitution inflammatory syndrome among HIV/Tuberculosis co-infected patients in Southern India. Indian J Med Microbiol 2018; 35:279-281. [PMID: 28681821 DOI: 10.4103/ijmm.ijmm_16_163] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Immune reconstitution inflammatory syndrome (IRIS) continues to be a complication in HIV/tuberculosis (TB) co-infected patients initiating highly active antiretroviral therapy (HAART). The aim of this study was to evaluate the risk factors associated with developing IRIS to identify a possible biomarker to predict or diagnose IRIS in patients initiating HAART. A total of 175 HIV/TB co-infected patients initiating HAART were followed up longitudinally during September 2010 to May 2013 attending a HIV care clinic in Chennai. Patients were followed up longitudinally after HAART initiation and baseline demographic, laboratory parameters and treatment characteristics between patients with IRIS events and those without IRIS events were compared. Chi-square or Fisher's exact test for categorical variables and a Wilcoxon rank-sum test for continuous variables were performed using SPSS, version 12.0 software. Patients with IRIS had a significantly lower median baseline CD4+ T-cell count (P = 0.0039). There were no differences in terms of sex, CD4 T-cell %, plasma viral load, time interval between initiating ATT and HAART between the IRIS and non-IRIS patients. Low CD4+ T-cell count (<100 cells/μL) could be used as a marker to screen and monitor patients initiating HAART.
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Affiliation(s)
- Ramachandran Vignesh
- Infectious Diseases Laboratory, Y. R. Gaitonde Centre for AIDS Research and Education, Chennai, Tamil Nadu, India; Laboratory-based Department, Universiti Kuala Lumpur Royal College of Medicine Perak, Ipoh, Malaysia
| | - Chinnambedu R Swathirajan
- Infectious Diseases Laboratory, Y. R. Gaitonde Centre for AIDS Research and Education, Chennai, Tamil Nadu, India
| | - Sunil S Solomon
- Medical Centre, Y. R. Gaitonde Centre for AIDS Research and Education, Chennai, Tamil Nadu, India; Department of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, USA
| | - Esaki Muthu Shankar
- Infectious Diseases Laboratory, Y. R. Gaitonde Centre for AIDS Research and Education, Chennai, Tamil Nadu, India
| | - Kailapuri G Murugavel
- Infectious Diseases Laboratory, Y. R. Gaitonde Centre for AIDS Research and Education, Chennai, Tamil Nadu, India
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9
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Janssen S, Osbak K, Holman R, Hermans S, Moekotte A, Knap M, Rossatanga E, Massinga-Loembe M, Alabi A, Adegnika A, Meenken C, van Vugt M, Kremsner PG, Meintjes G, van der Poll T, Grobusch MP. Low incidence of the immune reconstitution inflammatory syndrome among HIV-infected patients starting antiretroviral therapy in Gabon: a prospective cohort study. Infection 2017; 45:669-676. [PMID: 28349491 PMCID: PMC5630650 DOI: 10.1007/s15010-017-1000-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 02/21/2017] [Indexed: 11/30/2022]
Abstract
There is a paucity of data on the immune reconstitution inflammatory syndrome (IRIS) in the Central African region. We followed ART-naive HIV-infected patients initiating antiretroviral therapy in an HIV clinic in Gabon, for 6 months. Among 101 patients, IRIS was diagnosed in five. All IRIS cases were mucocutaneous manifestations. There were no cases of tuberculosis (TB) IRIS, but active TB (n = 20) was associated with developing other forms of IRIS (p = 0.02). Six patients died. The incidence of IRIS is low in Gabon, with mild, mucocutaneous manifestations.
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Affiliation(s)
- S Janssen
- Division of Internal Medicine, Department of Infectious Diseases, Center of Tropical Medicine and Travel Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1100 DD, Amsterdam, The Netherlands. .,Centre de Recherches Médicales en Lambaréné, Lambaréné, Gabon. .,Centre de Traitement Ambulatoire Lambaréné, Lambaréné, Gabon. .,Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany. .,Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa. .,Division of Internal Medicine, Department of Infectious Diseases, Center for Experimental and Molecular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands.
| | - K Osbak
- Division of Internal Medicine, Department of Infectious Diseases, Center of Tropical Medicine and Travel Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1100 DD, Amsterdam, The Netherlands.,Centre de Recherches Médicales en Lambaréné, Lambaréné, Gabon.,Centre de Traitement Ambulatoire Lambaréné, Lambaréné, Gabon
| | - R Holman
- Clinical Research Unit, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - S Hermans
- Department of Global Health, Academic Medical Center, Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, The Netherlands.,Faculty of Health Sciences, Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,Department of Internal Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - A Moekotte
- Division of Internal Medicine, Department of Infectious Diseases, Center of Tropical Medicine and Travel Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1100 DD, Amsterdam, The Netherlands.,Centre de Recherches Médicales en Lambaréné, Lambaréné, Gabon
| | - M Knap
- Division of Internal Medicine, Department of Infectious Diseases, Center of Tropical Medicine and Travel Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1100 DD, Amsterdam, The Netherlands.,Centre de Recherches Médicales en Lambaréné, Lambaréné, Gabon
| | - E Rossatanga
- Centre de Traitement Ambulatoire Lambaréné, Lambaréné, Gabon
| | - M Massinga-Loembe
- Centre de Recherches Médicales en Lambaréné, Lambaréné, Gabon.,Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany
| | - A Alabi
- Centre de Recherches Médicales en Lambaréné, Lambaréné, Gabon.,Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany
| | - A Adegnika
- Centre de Traitement Ambulatoire Lambaréné, Lambaréné, Gabon.,Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany
| | - C Meenken
- Department of Ophthalmology, VU Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
| | - M van Vugt
- Division of Internal Medicine, Department of Infectious Diseases, Center of Tropical Medicine and Travel Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1100 DD, Amsterdam, The Netherlands
| | - P G Kremsner
- Centre de Recherches Médicales en Lambaréné, Lambaréné, Gabon.,Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany
| | - G Meintjes
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - T van der Poll
- Division of Internal Medicine, Department of Infectious Diseases, Center for Experimental and Molecular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - M P Grobusch
- Division of Internal Medicine, Department of Infectious Diseases, Center of Tropical Medicine and Travel Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1100 DD, Amsterdam, The Netherlands.,Centre de Recherches Médicales en Lambaréné, Lambaréné, Gabon.,Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany.,Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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10
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Nuclear Factor of Activated T Cells and Cytokines Gene Expression of the T Cells in AIDS Patients with Immune Reconstitution Inflammatory Syndrome during Highly Active Antiretroviral Therapy. Mediators Inflamm 2017; 2017:1754741. [PMID: 28316373 PMCID: PMC5337872 DOI: 10.1155/2017/1754741] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 01/24/2017] [Indexed: 11/17/2022] Open
Abstract
Background. The etiology of immune reconstitution inflammatory syndrome (IRIS) in AIDS patients after the initiation of HAART remains unknown. Several researches indicated that the development of IRIS is associated with the production and variation of cytokines, whose gene expression are closely related to the Ca2+/CN-nuclear factor of activated T cells (NFAT) pathway. Methods. We studied the expression of NFAT isoforms and their major target cytokines genes in peripheral blood CD3+ T cells of subjects through fluorescence quantitative PCR and explored the expression changes of these genes before and after HAART. Results. After the initiation of HARRT, NFAT1, IL-6, and IL-8 gene expression showed a reversal trend in the CD3+ T cells of the IRIS group and changed from low expression before HARRT to high expression after HARRT. In particular, the relative gene expression of NFAT1 was markedly higher compared with the other three isoforms. The IRIS group also showed higher NFAT4, NFAT2, NFAT1, IL-1β, IL-10, IL-2, IL-18, and TNF-α gene expression than the non-IRIS group. Conclusion. This study suggested that high expression levels of IL-2, IL-6, IL-8, TNF-α, IL-1β, IL-10, IL-12, and IL-18 can predict the risk of IRIS. The increased expression of NFAT1 and NFAT4 may promote the expression of cytokines, such as IL-6, IL-8, and TNF-α, which may promote the occurrence of IRIS.
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11
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Li Z, Du S, Xiao Z, Xiao J. Clinical complications of antiretroviral therapy in HIV/TB patients in referral hospital, China. Future Virol 2017. [DOI: 10.2217/fvl-2016-0102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Aim: The aim was to highlight the clinical complications and to evaluate risk factors of mortality in Chinese HIV/TB patients. Methods: The etiology of clinical deterioration of Chinese HIV/TB patients were evaluated in 180 HIV-infected patients admitted in the Beijing Ditan Hospital between 1 January 2012 and 30 April 2014. Results & conclusion: AIDS-defining illnesses (20.0%) were the most common complication, followed by TB-associated immune reconstitution inflammatory syndrome (16.6%), drug-induced liver injury (11.1%), drug rash (11.1%), non-AIDS-defining illness (5.6%), as well as highly active antiretroviral therapy resistance (3.3%). The risk factors for mortality were tuberculous meningitis associated immune reconstitution inflammatory syndrome (OR: 152.614; CI: 18.324–1263.615; p < 0.001) and non-AIDS-defining illnesses (OR: 114.133; CI: 12.939–1006.752; p < 0.001), which will help remind physicians of the risk of clinical deterioration in HIV/TB patients after antiretroviral therapy in China.
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Affiliation(s)
- Ziyuan Li
- Wuhan Iron & Steel Corporation (WISCO) Worker's Hospital (Huarun-WISCO Hospital), Baiyushan Street, Qingshan District, Wuhan 430085, China
| | - Shuxu Du
- Beijing Shijitan Hospital, Capital Medical University, No.10 Tieyi Road, Haidian District, Beijing 100020, China
| | - Zhengyun Xiao
- Wuhan Iron & Steel Corporation (WISCO) Worker's Hospital (Huarun-WISCO Hospital), Baiyushan Street, Qingshan District, Wuhan 430085, China
| | - Jiang Xiao
- The National Clinical Key Department of Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, No. 8 Jingshun East Street, Chaoyang District, Beijing 100015, China
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12
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Changing Incidence and Risk Factors for Kaposi Sarcoma by Time Since Starting Antiretroviral Therapy: Collaborative Analysis of 21 European Cohort Studies. Clin Infect Dis 2016; 63:1373-1379. [PMID: 27535953 PMCID: PMC5091347 DOI: 10.1093/cid/ciw562] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 08/04/2016] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Kaposi sarcoma (KS) remains a frequent cancer in human immunodeficiency virus (HIV)-positive patients starting combination antiretroviral therapy (cART). We examined incidence rates and risk factors for developing KS in different periods after starting cART in patients from European observational HIV cohorts. METHODS We included HIV-positive adults starting cART after 1 January 1996. We analyzed incidence rates and risk factors for developing KS up to 90 and 180 days and 1, 2, 5, and 8 years after cART start and fitted univariable and multivariable Cox regression models. RESULTS We included 109 461 patients from 21 prospective clinical cohorts in Europe with 916 incident KS cases. The incidence rate per 100 000 person-years was highest 6 months after starting cART, at 953 (95% confidence interval, 866-1048), declining to 82 (68-100) after 5-8 years. In multivariable analyses adjusted for exposure group, origin, age, type of first-line regimen, and calendar year, low current CD4 cell counts increased the risk of developing KS throughout all observation periods after cART initiation. Lack of viral control was not associated with the hazard of developing KS in the first year after cART initiation, but was over time since starting cART increasingly positively associated (P < .001 for interaction). CONCLUSION In patients initiating cART, both incidence and risk factors for KS change with time since starting cART. Whereas soon after starting cART low CD4 cell count is the dominant risk factor, detectable HIV-1 RNA viral load becomes an increasingly important risk factor in patients who started cART several years earlier, independently of immunodeficiency.
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13
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Rohner E, Schmidlin K, Zwahlen M, Chakraborty R, Clifford G, Obel N, Grabar S, Verbon A, Noguera-Julian A, Collins IJ, Rojo P, Brockmeyer N, Campbell M, Chêne G, Prozesky H, Eley B, Stefan DC, Davidson A, Chimbetete C, Sawry S, Davies MA, Kariminia A, Vibol U, Sohn A, Egger M, Bohlius J. Kaposi Sarcoma Risk in HIV-Infected Children and Adolescents on Combination Antiretroviral Therapy From Sub-Saharan Africa, Europe, and Asia. Clin Infect Dis 2016; 63:1245-1253. [PMID: 27578823 PMCID: PMC5064163 DOI: 10.1093/cid/ciw519] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 07/21/2016] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The burden of Kaposi sarcoma (KS) in human immunodeficiency virus (HIV)-infected children and adolescents on combination antiretroviral therapy (cART) has not been compared globally. METHODS We analyzed cohort data from the International Epidemiologic Databases to Evaluate AIDS and the Collaboration of Observational HIV Epidemiological Research in Europe. We included HIV-infected children aged <16 years at cART initiation from 1996 onward. We used Cox models to calculate hazard ratios (HRs), adjusted for region and origin, sex, cART start year, age, and HIV/AIDS stage at cART initiation. RESULTS We included 24 991 children from eastern Africa, southern Africa, Europe and Asia; 26 developed KS after starting cART. Incidence rates per 100 000 person-years (PYs) were 86 in eastern Africa (95% confidence interval [CI], 55-133), 11 in southern Africa (95% CI, 4-35), and 81 (95% CI, 26-252) in children of sub-Saharan African (SSA) origin in Europe. The KS incidence rates were 0/100 000 PYs in children of non-SSA origin in Europe (95% CI, 0-50) and in Asia (95% CI, 0-27). KS risk was lower in girls than in boys (adjusted HR [aHR], 0.3; 95% CI, .1-.9) and increased with age (10-15 vs 0-4 years; aHR, 3.4; 95% CI, 1.2-10.1) and advanced HIV/AIDS stage (CDC stage C vs A/B; aHR, 2.4; 95% CI, .8-7.3) at cART initiation. CONCLUSIONS HIV-infected children from SSA but not those from other regions, have a high risk of developing KS after cART initiation. Early cART initiation in these children might reduce KS risk.
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14
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Mapesi H, Ramírez A, Tanner M, Hatz C, Letang E. Immune reconstitution inflammatory syndrome associated with dermatophytoses in two HIV-1 positive patients in rural Tanzania: a case report. BMC Infect Dis 2016; 16:495. [PMID: 27646953 PMCID: PMC5029027 DOI: 10.1186/s12879-016-1824-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 09/09/2016] [Indexed: 12/04/2022] Open
Abstract
Background Immune reconstitution inflammatory syndrome associated with dermatophytoses (tinea-IRIS) may cause considerable morbidity. Yet, it has been scarcely reported and is rarely considered in the differential diagnosis of HIV associated cutaneous lesions in Africa. If identified, it responds well to antifungals combined with steroids. We present two cases of suspected tinea-immune reconstitution inflammatory syndrome from a large HIV clinic in rural Tanzania. Cases presentation A first case was a 33 years-old female newly diagnosed HIV patient with CD4 count of 4 cells/μL (0 %), normal complete blood count, liver and renal function tests was started on co-formulated tenofovir/emtricitabine/efavirenz and prophylactic cotrimoxazole. Two weeks later she presented with exaggerated inflammatory hyperpigmented skin plaques with central desquamation, active borders and scratch lesions on the face, trunk and lower limbs. Tinea-IRIS was suspected and fluconazole (150 mg daily) and prednisolone (1 mg/Kg/day tapered down after 1 week) were given. Her symptoms subsided completely after 8 weeks of treatment, and her next CD4 counts had increased to 134 cells/μL (11 %). The second case was a 35 years-old female newly diagnosed with HIV. She had 1 CD4 cell/μL (0 %), haemoglobin 9.8 g/dl, and normal renal and liver function tests. Esophageal candidiasis and normocytic-normochromic anaemia were diagnosed. She received fluconazole, prophylactic cotrimoxazole and tenofovir/emtricitabine/efavirenz. Seven weeks later she presented with inflammatory skin plaques with elevated margins and central hyperpigmentation on the trunk, face and limbs in the frame of a good general recovery and increased CD4 counts (188 cells/μL, 6 %). Tinea-IRIS was suspected and treated with griseofulvin 500 mg daily and prednisolone 1 mg/Kg tapered down after 1 week, with total resolution of symptoms in 2 weeks. Conclusion The two cases had advanced immunosuppression and developed de-novo exaggerated manifestation of inflammatory lesions compatible with tinea corporis and tinea facies in temporal association with antiretroviral treatment initiation and good immunological response. This is compatible with unmasking tinea-IRIS, and reminds African clinicians about the importance of considering this entity in the differential diagnosis of patients with skin lesions developing after antiretroviral treatment initiation.
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Affiliation(s)
- Herry Mapesi
- Chronic Diseases Clinic of Ifakara, Ifakara Health Institute, P. O Box 53, Ifakara, Tanzania. .,University of Basel, Basel, Switzerland. .,Chronic Diseases Clinic of Ifakara, Swiss Tropical & Public Health Institute (Swiss TPH), Ifakara Health Institute (IHI), Ifakara branch, P.O. Box 53, Ifakara, Tanzania.
| | - Adrià Ramírez
- University Hospital Son Espases, Palma de Mallorca, Spain
| | - Marcel Tanner
- University of Basel, Basel, Switzerland.,Chronic Diseases Clinic of Ifakara, Swiss Tropical & Public Health Institute (Swiss TPH), Ifakara Health Institute (IHI), Ifakara branch, P.O. Box 53, Ifakara, Tanzania
| | - Christoph Hatz
- University of Basel, Basel, Switzerland.,Chronic Diseases Clinic of Ifakara, Swiss Tropical & Public Health Institute (Swiss TPH), Ifakara Health Institute (IHI), Ifakara branch, P.O. Box 53, Ifakara, Tanzania
| | - Emilio Letang
- Chronic Diseases Clinic of Ifakara, Ifakara Health Institute, P. O Box 53, Ifakara, Tanzania. .,University of Basel, Basel, Switzerland. .,Chronic Diseases Clinic of Ifakara, Swiss Tropical & Public Health Institute (Swiss TPH), Ifakara Health Institute (IHI), Ifakara branch, P.O. Box 53, Ifakara, Tanzania. .,ISGLOBAL, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain.
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15
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Namale PE, Abdullahi LH, Fine S, Kamkuemah M, Wilkinson RJ, Meintjes G. Paradoxical TB-IRIS in HIV-infected adults: a systematic review and meta-analysis. Future Microbiol 2016; 10:1077-99. [PMID: 26059627 DOI: 10.2217/fmb.15.9] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Paradoxical tuberculosis immune reconstitution inflammatory syndrome (TB-IRIS) was first described almost two decades ago. We undertook this systematic review and meta-analysis to collate findings across studies that have reported the incidence, clinical features, management and outcomes of paradoxical TB-IRIS. Forty studies that cumulatively reported 1048 paradoxical TB-IRIS cases were included. The pooled estimated incidence among patients with HIV-associated TB initiating antiretroviral therapy was 18% (95% CI: 16-21%). Frequent features were pulmonary and lymph node involvement. Hospitalization occurred in 25% (95% CI: 19-30%). In studies that reported treatment, corticosteroids were prescribed more frequently (38%; 95% CI: 27-48%) than nonsteroidal anti-inflammatory drugs (28%; 95% CI: 2-53%). Case fatality was 7% (95% CI: 4-11%), but death attributed to TB-IRIS occurred in 2% of cases (95% CI: 1-3%).
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Affiliation(s)
- Phiona E Namale
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Leila H Abdullahi
- Vaccines for Africa Initiative, Institute of Infectious Disease & Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Stacey Fine
- Department of Medicine, New Somerset Hospital, Cnr Beach & Lower Portswood Road, Green Point, Cape Town 8001, Western Cape, South Africa
| | - Monika Kamkuemah
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Robert J Wilkinson
- Department of Medicine, University of Cape Town, Cape Town, South Africa.,Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease & Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa.,Department of Medicine, Imperial College London, W2 1PG, UK.,Medical Research Council, National Institute of Medical Research, London, NW7 1AA, UK
| | - Graeme Meintjes
- Department of Medicine, University of Cape Town, Cape Town, South Africa.,Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease & Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa.,Department of Medicine, Imperial College London, W2 1PG, UK
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16
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Maixenchs M, Boene H, Anselmo R, Mindu C, Alonso P, Menéndez C, Macete E, Pool R, Letang E, Naniche D, Munguambe K. Post-ART Symptoms Were Not the Problem: A Qualitative Study on Adherence to ART in HIV-Infected Patients in a Mozambican Rural Hospital. PLoS One 2015; 10:e0137336. [PMID: 26332680 PMCID: PMC4558039 DOI: 10.1371/journal.pone.0137336] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 08/15/2015] [Indexed: 11/29/2022] Open
Abstract
Objective The objective of this qualitative study was to explore how clinical symptoms may affect adherence to antiretroviral therapy (ART) in HIV patients, and to explore factors, perceptions and attitudes related to adherence to therapy. Design A qualitative study was carried out in the context of the prospective cohort study “Evaluation of Immune Reconstitution Following Initiation of Highly Active Antiretroviral Treatment in Manhiça, Mozambique”. In-depth Interviews were conducted twice in a sub-sample of the study cohort (51 participants), at six-month intervals. Results Most participants (73%) knew that AIDS is a chronic disease and that ART does not cure it. Nine participants (18%) were non-adherent at some point and two (4%) abandoned ART. All participants but five reported having symptoms after starting ART, mainly attributed to pills needing time to act and body’s reaction to the treatment. In spite of the perceived severity of the symptoms, only two people reported they discontinued the treatment due to symptoms. Almost all participants reported feeling comfortable with the HIV clinic organization and procedures, but afraid of staff being hostile if they did not follow the rules or if the health worker visited their home. Family was one of the most important source of support according participants. Almost all participants with children said that a decisive factor to follow the treatment was the desire to be able to look after them. Conclusions Experiencing symptoms after starting treatment was not a barrier to adherence to ART. Factors related to adherence included control measures set up by the health facility (exhaustive follow up, support, information) and family and community support. Indirect ART-related expenses did jeopardise adherence.
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Affiliation(s)
- Maria Maixenchs
- Centro de Investigação em Saúde de Manhiça (CISM), Manhiça, Mozambique
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
- * E-mail:
| | - Helena Boene
- Centro de Investigação em Saúde de Manhiça (CISM), Manhiça, Mozambique
| | - Rui Anselmo
- Centro de Investigação em Saúde de Manhiça (CISM), Manhiça, Mozambique
| | - Carolina Mindu
- Centro de Investigação em Saúde de Manhiça (CISM), Manhiça, Mozambique
| | - Pedro Alonso
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
| | - Clara Menéndez
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
| | - Eusébio Macete
- Centro de Investigação em Saúde de Manhiça (CISM), Manhiça, Mozambique
| | - Robert Pool
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
- Centre for Social Science and Global Health, University of Amsterdam, Amsterdam, The Netherlands
| | - Emílio Letang
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
- Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Denise Naniche
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
| | - Khátia Munguambe
- Centro de Investigação em Saúde de Manhiça (CISM), Manhiça, Mozambique
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
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17
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New insights into immune reconstitution inflammatory syndrome of the central nervous system. Curr Opin HIV AIDS 2015; 9:572-8. [PMID: 25275706 DOI: 10.1097/coh.0000000000000107] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To highlight the importance of immune reconstitution inflammatory syndrome affecting the brain in HIV-infected individuals in the absence of opportunistic infections. To describe the varied clinical manifestations, unifying pathophysiological features and discuss the principles of management of this syndrome. RECENT FINDINGS Immune reconstitution inflammatory syndrome within the brain is commonly seen in patients with HIV infection upon initiation of antiretroviral drugs. The fulminant forms occur in the face of opportunistic infections or uncontrolled viral replication within the brain. In this case, the enhanced immune response is targeted against the microbial agent, and the brain suffers bystander damage. Treatment requires the combination of the antimicrobial agent, continued antiretrovirals and in some cases corticosteroids. It is increasingly being recognized that despite adequate control of viral replication in the brain, some patients develop a chronic form of T cell encephalitis which appears to be driven by continued production of HIV-Tat protein. In others, the immune response may be targeted against the host antigens in the brain. SUMMARY In patients with central nervous system-immune reconstitution inflammatory syndrome, the use of corticosteroids and strategies that prevent T cell migration into the brain may be needed. Extreme caution is necessary if viral eradication strategies are to be employed that involve activation of viral reservoirs, as these patients may be at risk for developing central nervous system-immune reconstitution inflammatory syndrome.
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18
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Manzardo C, Guardo AC, Letang E, Plana M, Gatell JM, Miro JM. Opportunistic infections and immune reconstitution inflammatory syndrome in HIV-1-infected adults in the combined antiretroviral therapy era: a comprehensive review. Expert Rev Anti Infect Ther 2015; 13:751-67. [PMID: 25860288 DOI: 10.1586/14787210.2015.1029917] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Despite the availability of effective combined antiretroviral treatment, many patients still present with advanced HIV infection, often accompanied by an AIDS-defining disease. A subgroup of patients starting antiretroviral treatment under these clinical conditions may experience paradoxical worsening of their disease as a result of an exaggerated immune response towards an active (but also subclinical) infectious agent, despite an appropriate virological and immunological response to the treatment. This clinical condition, known as immune reconstitution inflammatory syndrome, may cause significant morbidity and even mortality if it is not promptly recognized and treated. This review updates current knowledge about the incidence, diagnostic criteria, risk factors, clinical manifestations, and management of opportunistic infections and immune reconstitution inflammatory syndrome in the combined antiretroviral treatment era.
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Affiliation(s)
- Christian Manzardo
- Infectious Diseases Service and HIV Research Unit, Hospital Clinic - IDIBAPS, University of Barcelona, Villarroel 170, 08036 Barcelona, Spain
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19
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Incidence rate of Kaposi sarcoma in HIV-infected patients on antiretroviral therapy in Southern Africa: a prospective multicohort study. J Acquir Immune Defic Syndr 2015; 67:547-54. [PMID: 25393941 DOI: 10.1097/qai.0000000000000360] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The risk of Kaposi sarcoma (KS) among HIV-infected persons on antiretroviral therapy (ART) is not well defined in resource-limited settings. We studied KS incidence rates and associated risk factors in children and adults on ART in Southern Africa. METHODS We included patient data of 6 ART programs in Botswana, South Africa, Zambia, and Zimbabwe. We estimated KS incidence rates in patients on ART measuring time from 30 days after ART initiation to KS diagnosis, last follow-up visit, or death. We assessed risk factors (age, sex, calendar year, WHO stage, tuberculosis, and CD4 counts) using Cox models. FINDINGS We analyzed data from 173,245 patients (61% female, 8% children aged <16 years) who started ART between 2004 and 2010. Five hundred and sixty-four incident cases were diagnosed during 343,927 person-years (pys). The overall KS incidence rate was 164/100,000 pys [95% confidence interval (CI): 151 to 178]. The incidence rate was highest 30-90 days after ART initiation (413/100,000 pys; 95% CI: 342 to 497) and declined thereafter [86/100,000 pys (95% CI: 71 to 105), >2 years after ART initiation]. Male sex [adjusted hazard ratio (HR): 1.34; 95% CI: 1.12 to 1.61], low current CD4 counts (≥500 versus <50 cells/μL, adjusted HR: 0.36; 95% CI: 0.23 to 0.55), and age (5-9 years versus 30-39 years, adjusted HR: 0.20; 95% CI: 0.05 to 0.79) were relevant risk factors for developing KS. INTERPRETATION Despite ART, KS risk in HIV-infected persons in Southern Africa remains high. Early HIV testing and maintaining high CD4 counts is needed to further reduce KS-related morbidity and mortality.
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Walker NF, Scriven J, Meintjes G, Wilkinson RJ. Immune reconstitution inflammatory syndrome in HIV-infected patients. HIV AIDS (Auckl) 2015; 7:49-64. [PMID: 25709503 PMCID: PMC4334287 DOI: 10.2147/hiv.s42328] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Access to antiretroviral therapy (ART) is improving worldwide. Immune reconstitution inflammatory syndrome (IRIS) is a common complication of ART initiation. In this review, we provide an overview of clinical and epidemiological features of HIV-associated IRIS, current understanding of pathophysiological mechanisms, available therapy, and preventive strategies. The spectrum of HIV-associated IRIS is described, with a particular focus on three important pathogen-associated forms: tuberculosis-associated IRIS, cryptococcal IRIS, and Kaposi's sarcoma IRIS. While the clinical features and epidemiology are well described, there are major gaps in our understanding of pathophysiology and as a result therapeutic and preventative strategies are suboptimal. Timing of ART initiation is critical to reduce IRIS-associated morbidity. Improved understanding of the pathophysiology of IRIS will hopefully enable improved diagnostic modalities and better targeted treatments to be developed.
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Affiliation(s)
- Naomi F Walker
- Department of Medicine, Imperial College London, London, UK
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - James Scriven
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Graeme Meintjes
- Department of Medicine, Imperial College London, London, UK
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Robert J Wilkinson
- Department of Medicine, Imperial College London, London, UK
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- MRC National Institute of Medical Research, London, UK
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Schwartz AB, Tamuhla N, Steenhoff AP, Nkakana K, Letlhogile R, Chadborn TR, Kestler M, Zetola NM, Ravimohan S, Bisson GP. Outcomes in HIV-infected adults with tuberculosis at clinics with and without co-located HIV clinics in Botswana. Int J Tuberc Lung Dis 2014; 17:1298-303. [PMID: 24025381 DOI: 10.5588/ijtld.12.0861] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Gaborone, Botswana. OBJECTIVE To determine if starting anti-tuberculosis treatment at clinics in Gaborone without co-located human immunodeficiency virus (HIV) clinics would delay time to highly active antiretroviral therapy (HAART) initiation and be associated with lower survival compared to starting anti-tuberculosis treatment at clinics with on-site HIV clinics. DESIGN Retrospective cohort study. Subjects were HAART-naïve, aged ≥ 21 years with pulmonary tuberculosis (TB), HIV and CD4 counts ≤ 250 cells/mm(3) initiating anti-tuberculosis treatment between 2005 and 2010. Survival at completion of anti-tuberculosis treatment or at 6 months post-treatment initiation and time to HAART after anti-tuberculosis treatment initiation were compared by clinic type. RESULTS Respectively 259 and 80 patients from clinics without and with on-site HIV facilities qualified for the study. Age, sex, CD4, baseline sputum smears and loss to follow-up rate were similar by clinic type. Mortality did not differ between clinics without or with on-site HIV clinics (20/250, 8.0% vs. 8/79, 10.1%, relative risk 0.79, 95%CI 0.36-1.72), nor did median time to HAART initiation (respectively 63 and 66 days, P = 0.53). CONCLUSION In urban areas where TB and HIV programs are separate, geographic co-location alone without further integration may not reduce mortality or time to HAART initiation among co-infected patients.
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Affiliation(s)
- A B Schwartz
- New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
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Gopalan N, Andrade BB, Swaminathan S. Tuberculosis-immune reconstitution inflammatory syndrome in HIV: from pathogenesis to prediction. Expert Rev Clin Immunol 2014; 10:631-45. [PMID: 24580108 DOI: 10.1586/1744666x.2014.892828] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Tuberculosis-immune reconstitution inflammatory syndrome (TB-IRIS) is an exaggerated, dysregulated immune response against dead or viable antigens of Mycobacterium tuberculosis that frequently occurs after initiation of antiretroviral therapy despite an effective suppression of HIV viremia. Scientific advances in IRIS pathogenesis have led researchers and clinicians to postulate risk factors that could possibly predict this syndrome, in an attempt to reduce the incidence and the severity of IRIS, with appropriate anti-inflammatory therapy. This review is a summary of the available literature on pathogenic mechanisms involved from the macro to the micro level, the clinical spectrum, available predictors and the scope of these biomarkers to function as specific therapeutic targets, that could effectively modulate or ameliorate this syndrome in future.
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Affiliation(s)
- Narendran Gopalan
- National Institute for Research in Tuberculosis, 1, Mayor Sathyamoorthy Road, Chetpet, Chennai 600 031, India
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Abstract
Infectious diseases remain one of the most important causes of fever of unexplained origin (FUO). We review the spectrum of infectious diseases in the different clinical situations of patients with FUO, namely in classical FUO, in patients with HIV infection, in health care-associated or nosocomial FUO, and in immunocompromised patients with FUO. The most important question is which clinical features make a specific disease a candidate to cause FUO.
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Speicher DJ, Sehu MM, Johnson NW, Shaw DR. Successful treatment of an HIV-positive patient with unmasking Kaposi's sarcoma immune reconstitution inflammatory syndrome. J Clin Virol 2013; 57:282-5. [PMID: 23578530 DOI: 10.1016/j.jcv.2013.03.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Revised: 03/06/2013] [Accepted: 03/10/2013] [Indexed: 12/23/2022]
Abstract
BACKGROUND Kaposi's sarcoma (KS) continues to be the most common human immunodeficiency virus (HIV)-associated neoplasm with considerable morbidity and mortality. While lesions normally resolve upon initiation of antiretroviral therapy (ART), recrudescence or unmasking of KS lesions may occur as part of immune reconstitution inflammatory syndrome (IRIS). Treatment of unmasking KS-IRIS is not yet standardised. OBJECTIVES To report the successful treatment of a patient with fulminating mucocutaneous unmasking KS-IRIS by maintaining ART and using pegylated liposomal doxorubicin (PLD). STUDY DESIGN The patient, a 39-year-old HIV-positive male with no previous history of KS presented with a 2-week history of cutaneous and oral KS lesions that had disseminated rapidly over the preceding 4 days. The KS lesions appeared 8 weeks after recommencing ART. At the time of this presentation, his CD4+ count was 742 cells/mm(3) with a HIV viral load <400 copies/ml. ART was maintained and treatment with PLD commenced. RESULTS Despite the rapid dissemination of KS lesions, virus was undetectable in plasma. In a late-stage vasoformative lesion, immunohistochemistry (IHC) for human herpesvirus 8 (HHV-8) antigen was light and diffuse, with stippled deposits within endothelial cell nuclei. Virus extracted from the lesion was HHV-8 subtype A. The patient responded well to PLD, relapsed a year later, but after further PLD, has remained well for the following 5 years. CONCLUSION Despite the absence of HHV-8 viraemia, this is clearly a case of unmasking KS-IRIS. It demonstrates that this entity can be successfully treated by maintaining ART and administering PLD.
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Affiliation(s)
- David J Speicher
- School of Dentistry and Oral Health, Griffith University, Queensland, Australia.
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Abstract
We present a case of a 39-year-old male patient with Acquired Immune Deficiency Syndrome (AIDS) who developed
Mycobacterium tuberculosis related Immune Reconstitution Inflammatory Syndrome (IRIS) after initiation of Highly Active Antiretroviral Therapy (HAART) treatment. The inflammatory response resulted in mediastinal necrotic lymphadenopathy and subsequent perforation of the esophageal wall.
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Affiliation(s)
- Leonardo Valentin
- Department of Radiology, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Andrew Dinardo
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Elizabeth Chiao
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Laila Woc-Colburn
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Arun Nachiappan
- Department of Radiology, Baylor College of Medicine, Houston, TX, 77030, USA
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Haddow LJ, Moosa MYS, Mosam A, Moodley P, Parboosing R, Easterbrook PJ. Incidence, clinical spectrum, risk factors and impact of HIV-associated immune reconstitution inflammatory syndrome in South Africa. PLoS One 2012; 7:e40623. [PMID: 23152745 PMCID: PMC3495974 DOI: 10.1371/journal.pone.0040623] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Accepted: 10/03/2012] [Indexed: 11/18/2022] Open
Abstract
Background Immune reconstitution inflammatory syndrome (IRIS) is a widely recognised complication of antiretroviral therapy (ART), but there are still limited data from resource-limited settings. Our objective was to characterize the incidence, clinical spectrum, risk factors and contribution to mortality of IRIS in two urban ART clinics in South Africa. Methods and Findings 498 adults initiating ART in Durban, South Africa were followed prospectively for 24 weeks. IRIS diagnosis was based on consensus expert opinion, and classified by mode of presentation (paradoxical worsening of known opportunistic infection [OI] or unmasking of subclinical disease). 114 patients (22.9%) developed IRIS (36% paradoxical, 64% unmasking). Mucocutaneous conditions accounted for 68% of IRIS events, mainly folliculitis, warts, genital ulcers and herpes zoster. Tuberculosis (TB) accounted for 25% of IRIS events. 18/135 (13.3%) patients with major pre-ART OIs (e.g. TB, cryptococcosis) developed paradoxical IRIS related to the same OI. Risk factors for this type of IRIS were baseline viral load >5.5 vs. <4.5 log10 (adjusted hazard ratio 7.23; 95% confidence interval 1.35–38.76) and ≤30 vs. >30 days of OI treatment prior to ART (2.66; 1.16–6.09). Unmasking IRIS related to major OIs occurred in 25/498 patients (5.0%), and risk factors for this type of IRIS were baseline C-reactive protein ≥25 vs. <25 mg/L (2.77; 1.31–5.85), haemoglobin <10 vs. >12 g/dL (3.36; 1.32–8.52), ≥10% vs. <10% weight loss prior to ART (2.31; 1.05–5.11) and mediastinal lymphadenopathy on pre-ART chest x-ray (9.15; 4.10–20.42). IRIS accounted for 6/25 (24%) deaths, 13/65 (20%) hospitalizations and 10/35 (29%) ART interruptions or discontinuations. Conclusion IRIS occurred in almost one quarter of patients initiating ART, and accounted for one quarter of deaths in the first 6 months. Priority strategies to reduce IRIS-associated morbidity and mortality in ART programmes include earlier ART initiation before onset of advanced immunodeficiency, improved pre-ART screening for TB and cryptococcal infection, optimization of OI therapy prior to ART initiation, more intensive clinical monitoring in initial weeks of ART, and education of health care workers and patients about IRIS.
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Affiliation(s)
- Lewis John Haddow
- Centre for Sexual Health and HIV Research, Research Department of Infection and Population Health, University College London, London, United Kingdom
- Department of Infectious Diseases, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Mahomed-Yunus Suleman Moosa
- Department of Infectious Diseases, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Anisa Mosam
- Department of Dermatology, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Pravi Moodley
- Department of Virology, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- National Health Laboratory Services, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Raveen Parboosing
- Department of Virology, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- National Health Laboratory Services, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Philippa Jane Easterbrook
- Department of Infectious Diseases, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- * E-mail:
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Immune reconstitution inflammatory syndrome and the influence of T regulatory cells: a cohort study in The Gambia. PLoS One 2012; 7:e39213. [PMID: 22745716 PMCID: PMC3380048 DOI: 10.1371/journal.pone.0039213] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Accepted: 05/17/2012] [Indexed: 12/21/2022] Open
Abstract
Objective The factors associated with the development of immune reconstitution inflammatory syndrome in HIV patients commencing antiretroviral therapy have not been fully elucidated. Using a longitudinal study design, this study addressed whether alteration in the levels of T regulatory cells contributed to the development of IRIS in a West African cohort of HIV-1 and HIV-2 patients. Seventy-one HIV infected patients were prospectively recruited to the study and followed up for six months. The patients were categorized as IRIS or non-IRIS cases following published clinical guidelines. The levels of T regulatory cells were measured using flow cytometry at baseline and all follow-up visits. Baseline cytokine levels of IL-2, IL-6, IFN-γ, TNF-α, MIP-1β, IL-1, IL-12, IL-13, and IL-10 were measured in all patients. Results Twenty eight percent of patients (20/71) developed IRIS and were predominantly infected with HIV-1. Patients developing IRIS had lower nadir CD4 T cells at baseline (p = 0.03) and greater CD4 T cell reconstitution (p = 0.01) at six months post-ART. However, the development of IRIS was not influenced by the levels of T regulatory cells. Similarly, baseline cytokine levels did not predict the onset of IRIS. Conclusion The development of IRIS was not associated with differences in levels of T regulatory cells or baseline pro-inflammatory cytokines.
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Selective expansion of polyfunctional pathogen-specific CD4(+) T cells in HIV-1-infected patients with immune reconstitution inflammatory syndrome. Blood 2012; 119:3105-12. [PMID: 22219223 DOI: 10.1182/blood-2011-09-380840] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Since the introduction of highly active antiretroviral therapies (ART), the prognosis for HIV-1 patients has improved immensely. However, approximately 25% of patients can experience a variety of inflammatory symptoms that are collectively known as immune reconstitution inflammatory syndrome (IRIS). Studying the etiology and immunopathology of IRIS has been hampered by the fact that the symptoms and associated opportunistic infections are highly varied. We hypothesized that there is a common mechanism underlying IRIS pathogenesis and investigated a patient group with IRIS related to different pathogens. Functional and phenotypic characterization of PBMC samples was performed by polychromatic flow cytometry after in vitro stimulation with relevant antigenic preparations. In most patients, IRIS events were characterized by the robust increase of preexisting polyfunctional, highly differentiated effector CD4(+) T-cell responses that specifically targeted the antigens of the underlying co-infection. T-cell responses to HIV-1 or other underlying infections were not affected and did not differ between IRIS and non-IRIS patients. These data suggest that patients with IRIS do not have a generalized T-cell dysfunction; instead, IRIS represents a dysregulated CD4(+) T-cell response against residual opportunistic infection antigen. These studies were registered at www.clinical-trials.gov as NCT00557570 and NCT00286767.
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Mehla R, Bivalkar-Mehla S, Chauhan A. A flavonoid, luteolin, cripples HIV-1 by abrogation of tat function. PLoS One 2011; 6:e27915. [PMID: 22140483 PMCID: PMC3227592 DOI: 10.1371/journal.pone.0027915] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Accepted: 10/27/2011] [Indexed: 12/17/2022] Open
Abstract
Despite the effectiveness of combination antiretroviral treatment (cART) against HIV-1, evidence indicates that residual infection persists in different cell types. Intensification of cART does not decrease the residual viral load or immune activation. cART restricts the synthesis of infectious virus but does not curtail HIV-1 transcription and translation from either the integrated or unintegrated viral genomes in infected cells. All treated patients with full viral suppression actually have low-level viremia. More than 60% of treated individuals also develop minor HIV-1 -associated neurocognitive deficits (HAND) due to residual virus and immune activation. Thus, new therapeutic agents are needed to curtail HIV-1 transcription and residual virus. In this study, luteolin, a dietary supplement, profoundly reduced HIV-1 infection in reporter cells and primary lymphocytes. HIV-1inhibition by luteolin was independent of viral entry, as shown by the fact that wild-type and VSV-pseudotyped HIV-1 infections were similarly inhibited. Luteolin was unable to inhibit viral reverse transcription. Luteolin had antiviral activity in a latent HIV-1 reactivation model and effectively ablated both clade-B- and -C -Tat-driven LTR transactivation in reporter assays but had no effect on Tat expression and its sub-cellular localization. We conclude that luteolin confers anti-HIV-1 activity at the Tat functional level. Given its biosafety profile and ability to cross the blood-brain barrier, luteolin may serve as a base flavonoid to develop potent anti-HIV-1 derivatives to complement cART.
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Affiliation(s)
- Rajeev Mehla
- Department of Pathology, Microbiology and Immunology, University of South Carolina School of Medicine, Columbia, South Carolina, United States of America
| | - Shalmali Bivalkar-Mehla
- Department of Pathology, Microbiology and Immunology, University of South Carolina School of Medicine, Columbia, South Carolina, United States of America
| | - Ashok Chauhan
- Department of Pathology, Microbiology and Immunology, University of South Carolina School of Medicine, Columbia, South Carolina, United States of America
- Department of Pharmacology, Physiology and Neuroscience, University of South Carolina School of Medicine, Columbia, South Carolina, United States of America
- * E-mail:
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