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Santin M, Escrich C, Majòs C, Llaberia M, Grijota MD, Grau I. Tumor necrosis factor antagonists for paradoxical inflammatory reactions in the central nervous system tuberculosis: Case report and review. Medicine (Baltimore) 2020; 99:e22626. [PMID: 33120751 PMCID: PMC7581161 DOI: 10.1097/md.0000000000022626] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Paradoxical reaction/immune reconstitution inflammatory syndrome is common in patients with central nervous system tuberculosis. Management relies on high-dose corticosteroids and surgery when feasible. PATIENT CONCERN We describe 2 cases of HIV-negative patients with corticosteroid-refractory paradoxical reactions of central nervous system tuberculosis. DIAGNOSES The 2 patients experienced clinical impairment shortly after starting therapy for TB, and magnetic resonance imaging showed the presence of tuberculomas, leading to the diagnosis of a paradoxical reaction. INTERVENTIONS We added infliximab, an anti-tumor necrosis factor (TNF)-alpha monoclonal antibody, to the dexamethasone. OUTCOMES Both patients had favorable outcomes, 1 achieving full recovery but 1 suffering neurologic sequelae. LESSONS Clinicians should be aware of the risk of paradoxical reactions/immune reconstitution inflammatory syndrome when treating patients with tuberculosis of the central nervous system and should consider the prompt anti-TNF-α agents in cases not responding to corticosteroids.
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Affiliation(s)
- Miguel Santin
- Tuberculosis Unit, Service of Infectious Diseases, Bellvitge University Hospital-Bellvitge Institute for Biomedical Research (IDIBELL)
- Department of Clinical Sciences, University of Barcelona; L’Hospitalet de Llobregat
| | - Cristina Escrich
- Service of Internal Medicine, Hospital Verge de la Cinta; Tortosa
| | - Carles Majòs
- Department of Neuroradiology, Bellvitge University Hospital-Bellvitge Institute for Biomedical Research (IDIBELL)
| | - Mariona Llaberia
- Service of Infectious Diseases, Bellvitge University Hospital-Bellvitge Institute for Biomedical Research (IDIBELL), Spain
| | - Maria D. Grijota
- Tuberculosis Unit, Service of Infectious Diseases, Bellvitge University Hospital-Bellvitge Institute for Biomedical Research (IDIBELL)
| | - Imma Grau
- Department of Clinical Sciences, University of Barcelona; L’Hospitalet de Llobregat
- Service of Infectious Diseases, Bellvitge University Hospital-Bellvitge Institute for Biomedical Research (IDIBELL), Spain
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2
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Nyirenda M, Ngongondo M, Kang M, Umbleja T, Krown SE, Godfrey C, Samaneka W, Mngqibisa R, Hoagland B, Mwelase N, Caruso S, Martinez-Maza O, Dittmer DP, Borok M, Hosseinipour MC, Campbell TB. Early Progression and Immune Reconstitution Inflammatory Syndrome During Treatment of Mild-To-Moderate Kaposi Sarcoma in Sub-Saharan Africa and South America: Incidence, Long-Term Outcomes, and Effects of Early Chemotherapy. J Acquir Immune Defic Syndr 2020; 84:422-429. [PMID: 32265361 PMCID: PMC7365262 DOI: 10.1097/qai.0000000000002361] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Early progression of AIDS-associated Kaposi sarcoma (KS-PD) and immune reconstitution inflammatory syndrome (KS-IRIS) sometimes occur after the initiation of antiretroviral therapy (ART). METHODS Early KS-PD and KS-IRIS were assessed in the A5264/AMC-067 trial in which participants with mild-to-moderate AIDS-KS were randomized to initiate ART with either immediate or as-needed oral etoposide. Early KS-PD was defined as tumor progression within 12 weeks of ART initiation. When investigators had concern that early KS-PD was KS-IRIS, additional evaluations were performed. Suspected KS-IRIS was defined as early KS-PD accompanied by a CD4 count increase of ≥50 cells per cubic millimeter or plasma HIV-1 RNA decrease of ≥0.5 log10 copies/mL. Clinical outcome was a composite end point categorized as failure, stable, and response at 48 and 96 weeks compared with baseline. RESULTS Fifty of 190 participants had early KS-PD (27%): 28 had KS-IRIS and 22 were not evaluated for KS-IRIS. Early KS-PD and KS-IRIS incidences with immediate etoposide versus ART alone were 16% versus 39%, and 7% versus 21%, respectively. Week 48 clinical outcome was 45% failure, 18% stable, and 37% response for no early KS-PD; 82% failure, 2% stable, and 16% response for early KS-PD; and 88% failure, 0% stable, and 12% response for KS-IRIS. Cumulative incidence of KS tumor response by week 96 was 64% for no early KS-PD, 22% with early KS-PD, and 18% with KS-IRIS. CONCLUSIONS Early KS-PD, including suspected KS-IRIS, was common after starting ART for AIDS-KS and was associated with worse long-term clinical outcomes. Starting ART concurrently with etoposide reduced the incidence of both early KS-PD and KS-IRIS compared with ART alone.
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Affiliation(s)
- Mulinda Nyirenda
- Johns Hopkins Project, University of Malawi College of Medicine, Blantyre, Malawi
| | | | - Minhee Kang
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Triin Umbleja
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA
| | | | - Catherine Godfrey
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Wadzanai Samaneka
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Rosie Mngqibisa
- Durban International Clinical Research Site, Enhancing Care Foundation, Durban, South Africa
| | - Brenda Hoagland
- Oswaldo Cruz Foundation, Evandro Chagas National Institute of Infectious Diseases, Rio de Janeiro, Brazil
| | | | | | - Oto Martinez-Maza
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA
| | - Dirk P Dittmer
- Department of Microbiology & Immunology, University of North Carolina School of Medicine, and Lineberger Comprehensive Cancer Center, Chapel Hill, NC; and
| | - Margaret Borok
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Mina C Hosseinipour
- UNC Project Malawi, Lilongwe, Malawi
- Department of Microbiology & Immunology, University of North Carolina School of Medicine, and Lineberger Comprehensive Cancer Center, Chapel Hill, NC; and
| | - Thomas B Campbell
- Department of Medicine/Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, CO
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de Sá NBR, Ribeiro-Alves M, da Silva TP, Pilotto JH, Rolla VC, Giacoia-Gripp CBW, Scott-Algara D, Morgado MG, Teixeira SLM. Clinical and genetic markers associated with tuberculosis, HIV-1 infection, and TB/HIV-immune reconstitution inflammatory syndrome outcomes. BMC Infect Dis 2020; 20:59. [PMID: 31959123 PMCID: PMC6971853 DOI: 10.1186/s12879-020-4786-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 01/09/2020] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Tuberculosis (TB) and AIDS are the leading causes of infectious disease death worldwide. In some TB-HIV co-infected individuals treated for both diseases simultaneously, a pathological inflammatory reaction termed immune reconstitution inflammatory syndrome (IRIS) may occur. The risk factors for IRIS are not fully defined. We investigated the association of HLA-B, HLA-C, and KIR genotypes with TB, HIV-1 infection, and IRIS onset. METHODS Patients were divided into four groups: Group 1- TB+/HIV+ (n = 88; 11 of them with IRIS), Group 2- HIV+ (n = 24), Group 3- TB+ (n = 24) and Group 4- healthy volunteers (n = 26). Patients were followed up at INI/FIOCRUZ and HGNI (Rio de Janeiro/Brazil) from 2006 to 2016. The HLA-B and HLA-C loci were typed using SBT, NGS, and KIR genes by PCR-SSP. Unconditional logistic regression models were performed for Protection/risk estimation. RESULTS Among the individuals with TB as the outcome, KIR2DS2 was associated with increased risk for TB onset (aOR = 2.39, P = 0.04), whereas HLA-B*08 and female gender were associated with protection against TB onset (aOR = 0.23, P = 0.03, and aOR = 0.33, P = 0.01, respectively). Not carrying KIR2DL3 (aOR = 0.18, P = 0.03) and carrying HLA-C*07 (aOR = 0.32, P = 0.04) were associated with protection against TB onset among HIV-infected patients. An increased risk for IRIS onset was associated with having a CD8 count ≤500 cells/mm3 (aOR = 18.23, P = 0.016); carrying the KIR2DS2 gene (aOR = 27.22, P = 0.032), the HLA-B*41 allele (aOR = 68.84, P = 0.033), the KIR2DS1 + HLA-C2 pair (aOR = 28.58, P = 0.024); and not carrying the KIR2DL3 + HLA-C1/C2 pair (aOR = 43.04, P = 0.034), and the KIR2DL1 + HLA-C1/C2 pair (aOR = 43.04, P = 0.034), CONCLUSIONS: These results suggest the participation of these genes in the immunopathogenic mechanisms related to the conditions studied. This is the first study demonstrating an association of HLA-B*41, KIR2DS2, and KIR + HLA-C pairs with IRIS onset among TB-HIV co-infected individuals.
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Affiliation(s)
- Nathalia Beatriz Ramos de Sá
- Laboratory of AIDS & Molecular Immunology, Oswaldo Cruz Institute, FIOCRUZ. Av. Brasil 4365, Leonidas Deane Building, room 401, Rio de Janeiro, 21040-360, Brazil
| | - Marcelo Ribeiro-Alves
- Laboratory of Clinical Research on STD/AIDS, National Institute of Infectious Diseases Evandro Chagas, FIOCRUZ, Rio de Janeiro, Brazil
| | - Tatiana Pereira da Silva
- Laboratory of AIDS & Molecular Immunology, Oswaldo Cruz Institute, FIOCRUZ. Av. Brasil 4365, Leonidas Deane Building, room 401, Rio de Janeiro, 21040-360, Brazil
| | - Jose Henrique Pilotto
- Laboratory of AIDS & Molecular Immunology, Oswaldo Cruz Institute, FIOCRUZ. Av. Brasil 4365, Leonidas Deane Building, room 401, Rio de Janeiro, 21040-360, Brazil
- Nova Iguaçu General Hospital, Nova Iguaçu, Rio de Janeiro, Brazil
| | - Valeria Cavalcanti Rolla
- Clinical Research Laboratory on Mycobacteria, National Institute of Infectious Diseases Evandro Chagas, FIOCRUZ, Rio de Janeiro, Brazil
| | - Carmem B W Giacoia-Gripp
- Laboratory of AIDS & Molecular Immunology, Oswaldo Cruz Institute, FIOCRUZ. Av. Brasil 4365, Leonidas Deane Building, room 401, Rio de Janeiro, 21040-360, Brazil
| | - Daniel Scott-Algara
- Unité de Biologie Cellulaire des Lymphocytes, Institut Pasteur, Paris, France
| | - Mariza Gonçalves Morgado
- Laboratory of AIDS & Molecular Immunology, Oswaldo Cruz Institute, FIOCRUZ. Av. Brasil 4365, Leonidas Deane Building, room 401, Rio de Janeiro, 21040-360, Brazil.
| | - Sylvia Lopes Maia Teixeira
- Laboratory of AIDS & Molecular Immunology, Oswaldo Cruz Institute, FIOCRUZ. Av. Brasil 4365, Leonidas Deane Building, room 401, Rio de Janeiro, 21040-360, Brazil
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Trunfio M, Manini C, Trentalange A, Boghi A, Audagnotto S, Imperiale D, Taraglio S, Bonora S, Di Perri G, Calcagno A. The "milky way" galaxy of HIV-related central nervous system immune reaction syndromes. J Neurovirol 2019; 25:887-892. [PMID: 31214917 DOI: 10.1007/s13365-019-00769-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 05/18/2019] [Accepted: 05/24/2019] [Indexed: 11/26/2022]
Abstract
The landscape of central nervous system HIV infection is rapidly changing, leading to the recognition of a new constellation of overlapping syndromes and to a better insight for the elder ones. Among these, progressive multifocal leukoencephalopathy (PML) still poses several diagnostic and therapeutic challenges; nevertheless, recent developments in understanding PML in patients with multiple sclerosis may have benefitted HIV-positive patients suffering from PML too. We describe a peculiar case of PML-immune reconstitution inflammatory syndrome (IRIS) presenting a punctate pattern with "milky way" appearance on magnetic resonance imaging. Despite the fact that brain imaging and histopathology remain the mainstays for extricating through the expanding galaxy of HIV-related central nervous system dysimmune syndromes and although punctate pattern has been already well acknowledged as a suggestive finding of PML among patients on natalizumab, this radiological presentation is still poorly recognised in AIDS-related PML cases, leading to possible life-threatening diagnostic delays. This is also the first report about intravenous immunoglobulin treatment in AIDS-related PML-IRIS; the favourable clinical and radiological outcome of our case and the preliminary administrations of intravenous immunoglobulins in natalizumab-associated PML-IRIS from literature support probable benefits also among HIV-positive patients.
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Affiliation(s)
- Mattia Trunfio
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Torino, Corso Svizzera 164, 10149, Torino, Italy.
| | - Claudia Manini
- Unit of Pathology, San Giovanni Bosco Hospital, Piazza Donatore di Sangue 3, 10154, Torino, Italy
| | - Alice Trentalange
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Torino, Corso Svizzera 164, 10149, Torino, Italy
| | - Andrea Boghi
- Unit of Neuroradiology, San Giovanni Bosco Hospital, Piazza Donatore di Sangue 3, 10154, Torino, Italy
| | - Sabrina Audagnotto
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Torino, Corso Svizzera 164, 10149, Torino, Italy
| | - Daniele Imperiale
- Unit of Neurology, Maria Vittoria Hospital, Via Luigi Cibrario 72, 10144, Torino, Italy
| | - Stefano Taraglio
- Unit of Pathology, San Giovanni Bosco Hospital, Piazza Donatore di Sangue 3, 10154, Torino, Italy
| | - Stefano Bonora
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Torino, Corso Svizzera 164, 10149, Torino, Italy
| | - Giovanni Di Perri
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Torino, Corso Svizzera 164, 10149, Torino, Italy
| | - Andrea Calcagno
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Torino, Corso Svizzera 164, 10149, Torino, Italy
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Zhang ZQ, Wang J, Hoy Z, Keegan A, Bhagwat S, Gigliotti F, Wright TW. Neither classical nor alternative macrophage activation is required for Pneumocystis clearance during immune reconstitution inflammatory syndrome. Infect Immun 2015; 83:4594-603. [PMID: 26371121 PMCID: PMC4645389 DOI: 10.1128/iai.00763-15] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 09/05/2015] [Indexed: 11/20/2022] Open
Abstract
Pneumocystis is a respiratory fungal pathogen that causes pneumonia (Pneumocystis pneumonia [PcP]) in immunocompromised patients. Alveolar macrophages are critical effectors for CD4(+) T cell-dependent clearance of Pneumocystis, and previous studies found that alternative macrophage activation accelerates fungal clearance during PcP-related immune reconstitution inflammatory syndrome (IRIS). However, the requirement for either classically or alternatively activated macrophages for Pneumocystis clearance has not been determined. Therefore, RAG2(-/-) mice lacking either the interferon gamma (IFN-γ) receptor (IFN-γR) or interleukin 4 receptor alpha (IL-4Rα) were infected with Pneumocystis. These mice were then immune reconstituted with wild-type lymphocytes to preserve the normal T helper response while preventing downstream effects of Th1 or Th2 effector cytokines on macrophage polarization. As expected, RAG2(-/-) mice developed severe disease but effectively cleared Pneumocystis and resolved IRIS. Neither RAG/IFN-γR(-/-) nor RAG/IL-4Rα(-/-) mice displayed impaired Pneumocystis clearance. However, RAG/IFN-γR(-/-) mice developed a dysregulated immune response, with exacerbated IRIS and greater pulmonary function deficits than those in RAG2 and RAG/IL-4Rα(-/-) mice. RAG/IFN-γR(-/-) mice had elevated numbers of lung CD4(+) T cells, neutrophils, eosinophils, and NK cells but severely depressed numbers of lung CD8(+) T suppressor cells. Impaired lung CD8(+) T cell responses in RAG/IFN-γR(-/-) mice were associated with elevated lung IFN-γ levels, and neutralization of IFN-γ restored the CD8 response. These data demonstrate that restricting the ability of macrophages to polarize in response to Th1 or Th2 cytokines does not impair Pneumocystis clearance. However, a cell type-specific IFN-γ/IFN-γR-dependent mechanism regulates CD8(+) T suppressor cell recruitment, limits immunopathogenesis, preserves lung function, and enhances the resolution of PcP-related IRIS.
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MESH Headings
- Animals
- CD8-Positive T-Lymphocytes/immunology
- CD8-Positive T-Lymphocytes/microbiology
- CD8-Positive T-Lymphocytes/pathology
- DNA-Binding Proteins/deficiency
- DNA-Binding Proteins/genetics
- DNA-Binding Proteins/immunology
- Eosinophils/immunology
- Eosinophils/microbiology
- Eosinophils/pathology
- Gene Expression Regulation
- Host-Pathogen Interactions
- Immune Reconstitution Inflammatory Syndrome/genetics
- Immune Reconstitution Inflammatory Syndrome/immunology
- Immune Reconstitution Inflammatory Syndrome/microbiology
- Immune Reconstitution Inflammatory Syndrome/pathology
- Killer Cells, Natural/immunology
- Killer Cells, Natural/microbiology
- Killer Cells, Natural/pathology
- Lung/immunology
- Lung/microbiology
- Lung/pathology
- Macrophage Activation
- Macrophages, Alveolar/immunology
- Macrophages, Alveolar/microbiology
- Macrophages, Alveolar/pathology
- Mice
- Mice, Knockout
- Mice, SCID
- Neutrophils/immunology
- Neutrophils/microbiology
- Neutrophils/pathology
- Pneumocystis/immunology
- Pneumocystis/pathogenicity
- Pneumonia, Pneumocystis/genetics
- Pneumonia, Pneumocystis/immunology
- Pneumonia, Pneumocystis/microbiology
- Pneumonia, Pneumocystis/pathology
- Receptors, Cell Surface/deficiency
- Receptors, Cell Surface/genetics
- Receptors, Cell Surface/immunology
- Receptors, Interferon/deficiency
- Receptors, Interferon/genetics
- Receptors, Interferon/immunology
- Signal Transduction
- T-Lymphocytes, Helper-Inducer/immunology
- T-Lymphocytes, Helper-Inducer/microbiology
- T-Lymphocytes, Helper-Inducer/pathology
- Th1-Th2 Balance
- Interferon gamma Receptor
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Affiliation(s)
- Zhuo-Qian Zhang
- Department of Microbiology and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Jing Wang
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Zachary Hoy
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Achsah Keegan
- Center for Vascular and Inflammatory Diseases, Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Samir Bhagwat
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Francis Gigliotti
- Department of Microbiology and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Terry W Wright
- Department of Microbiology and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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Abstract
Recovery from severe immunosuppression requires hematopoietic stem cell reconstitution and effective thymopoiesis to restore a functional immune cell repertoire. Herein, a model of immune cell reconstitution consequent to potentially lethal doses of irradiation is described, which may be valuable in evaluating potential medical countermeasures. Male rhesus macaques were total body irradiated by exposure to 6.00 Gy 250 kVp x-radiation (midline tissue dose, 0.13 Gy min), resulting in an approximate LD10/60 (n = 5/59). Animals received medical management, and hematopoietic and immune cell recovery was assessed (n ≤ 14) through 370 d post exposure. A subset of animals (n ≤ 8) was examined through 700 d. Myeloid recovery was assessed by neutrophil and platelet-related parameters. Lymphoid recovery was assessed by the absolute lymphocyte count and FACS-based phenotyping of B- and T-cell subsets. Recent thymic emigrants were identified by T cell receptor excision circle quantification. Severe neutropenia, lymphopenia, and thrombocytopenia resolved within 30 d. Total CD3+ cells μL required 60 d to reach values 60% of normal, followed by subsequent slow recovery to approximately normal by 180 d post irradiation. Recovery of CD3+4+ and CD3+8+ cell memory and naïve subsets were markedly different. Memory populations were ≥ 100% of normal by day 60, whereas naïve populations were only 57% normal at 180 d and never fully recovered to baseline post irradiation. Total (CD20+) B cells μL were within normal levels by 77 d post exposure. This animal model elucidates the variable T- and B-cell subset recovery kinetics after a potentially lethal dose of total-body irradiation that are dependent on marrow-derived stem and progenitor cell recovery, peripheral homeostatic expansion, and thymopoiesis.
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Affiliation(s)
- Ann M. Farese
- University of Maryland, School of Medicine, Dept. of Radiation Oncology, Baltimore, MD
| | - Kim G. Hankey
- University of Maryland, School of Medicine, Dept. of Radiation Oncology, Baltimore, MD
| | | | - Thomas J. MacVittie
- University of Maryland, School of Medicine, Dept. of Radiation Oncology, Baltimore, MD
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Nambudiri VE, Kersellius R, Harp J, Maniar JK, Maurer TA. Idiopathic Pyoderma Gangrenosum as a Novel Manifestation of the HIV Immune Reconstitution Inflammatory Syndrome: A Report of Three Cases. J Assoc Physicians India 2015; 63:72-76. [PMID: 26731836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The initiation of antiretroviral treatment for individuals with HIV may be accompanied by a paradoxical flare of underlying inflammatory diseases, the recurrence of dormant infections, or worsening of prior treated opportunistic infections, termed the immune reconstitution inflammatory syndrome (IRIS). Cutaneous manifestations of IRIS are common. Pyoderma gangrenosum is a neutrophilic dermatosis postulated to reflect disrupted innate immune regulation causing altered neutrophil chemotaxis. It is uncommonly reported in association with HIV. In this case series, we present three cases of IRIS manifesting with pyoderma gangrenosum in individuals with HIV from India and the United States to raise awareness of this previously undescribed presentation and discuss the treatment challenges in the management of these patients.
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Galliani JP, McCardle T, Johansen N, Nozile W. A 29-year-old man with exophytic Kaposi sarcoma and edema of the bilateral legs in the setting of immune reconstitution inflammatory syndrome. Dermatol Online J 2013; 19:19272. [PMID: 24021450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 08/13/2013] [Indexed: 06/02/2023] Open
Abstract
A 29-year-old man with a history of HIV, previously noncompliant with antiretroviral therapy, restarted highly active antiretroviral therapy (HAART) 4 weeks prior to the sudden development of multiple tender exophytic friable tumors and subcutaneous nodules of the thighs. Herein we present a patient with Kaposi sarcoma in the setting of immune reconstitution inflammatory syndrome.
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9
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Tadokera R, Wilkinson KA, Meintjes GA, Skolimowska KH, Matthews K, Seldon R, Rangaka MX, Maartens G, Wilkinson RJ. Role of the interleukin 10 family of cytokines in patients with immune reconstitution inflammatory syndrome associated with HIV infection and tuberculosis. J Infect Dis 2013; 207:1148-56. [PMID: 23303806 PMCID: PMC3583273 DOI: 10.1093/infdis/jit002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2012] [Accepted: 10/30/2012] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The interleukin 10 (IL-10) family comprises cytokines structurally related to IL-10 that share signaling receptors that have conserved signaling cascades. The immunopathogenesis of immune reconstitution inflammatory syndrome (IRIS) in patients with human immunodeficiency virus (HIV) infection and tuberculosis remains incompletely understood. We hypothesized that a deficiency of IL-10 and its homologs may contribute to the immunopathology of IRIS in these patients. METHODS We performed a case-control analysis involving patients with HIV infection and tuberculosis who had IRIS at clinical presentation (tuberculosis-IRIS) and similar patients with HIV infection and tuberculosis who did not develop tuberculosis-IRIS (non-IRIS). Peripheral blood mononuclear cells (PBMCs) were cultured in the presence or absence of heat-killed Mycobacterium tuberculosis for 6 and 24 hours. Messenger RNA was analyzed by quantitative reverse transcription polymerase chain reaction analysis. Cytokine concentrations in serum were also determined. RESULTS Cultures of PBMCs stimulated with M. tuberculosis for 24 hours yielded higher IL-10 and interleukin 22 (IL-22) transcript levels for tuberculosis-IRIS patients, compared with non-IRIS patients. Analysis of corresponding serum samples showed significantly higher concentrations of IL-10 and IL-22 in tuberculosis-IRIS patients, compared with non-IRIS patients. CONCLUSIONS IL-10 and IL-22 were differentially induced in PBMCs from tuberculosis-IRIS patients after in vitro stimulation, and higher concentrations of their corresponding proteins were detected in serum (in vivo). The higher levels of IL-10 observed in this study may represent a compensatory antiinflammatory response during tuberculosis-IRIS. The elevated levels of IL-22 suggest an association between this cytokine and immunopathology during tuberculosis-IRIS.
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Affiliation(s)
- Rebecca Tadokera
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Diseases and Molecular Medicine
| | - Katalin A. Wilkinson
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Diseases and Molecular Medicine
- MRC National Institute for Medical Research, London, United Kingdom
| | - Graeme A. Meintjes
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Diseases and Molecular Medicine
- Department of Medicine, University of Cape Town, Cape Town
- Infectious Diseases Unit, G. F. Jooste Hospital, Manenberg, South Africa
- Department of Medicine, Imperial College London
| | - Keira H. Skolimowska
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Diseases and Molecular Medicine
| | - Kerryn Matthews
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Diseases and Molecular Medicine
| | - Ronnett Seldon
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Diseases and Molecular Medicine
| | - Molebogeng X. Rangaka
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Diseases and Molecular Medicine
| | - Gary Maartens
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Diseases and Molecular Medicine
- Division of Clinical Pharmacology
- Department of Medicine, University of Cape Town, Cape Town
- Infectious Diseases Unit, G. F. Jooste Hospital, Manenberg, South Africa
| | - Robert J. Wilkinson
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Diseases and Molecular Medicine
- Department of Medicine, University of Cape Town, Cape Town
- Infectious Diseases Unit, G. F. Jooste Hospital, Manenberg, South Africa
- Department of Medicine, Imperial College London
- MRC National Institute for Medical Research, London, United Kingdom
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Tajima K, Kohno K, Shiono Y, Suzuki I, Kato Y, Hiroshima Y, Yamamoto M, Ohtake H, Iwaba A, Yamakawa M, Kato T. Acute kidney injury and inflammatory immune reconstitution syndrome in mixed genotype (A/E) hepatitis B virus co-infection in HIV-associated lymphoma. Int J Clin Exp Pathol 2013; 6:536-542. [PMID: 23411777 PMCID: PMC3563184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Accepted: 12/29/2012] [Indexed: 06/01/2023]
Abstract
We report a first case of HIV-associated lymphoma (HAL) presenting with acute kidney injury (AKI) and inflammatory immune reconstitution syndrome (IRIS). A 39-year-old male, treated with nonsteroidal anti-inflammatory drugs (NSAIDs) for one month prior to admission, developed AKI, left testicular tumor, and recurrent swelling of the right parotid gland. A resected testicular tumor exhibited features intermediate between diffuse large B-cell lymphoma and Burkitt lymphoma. Renal biopsy showed hydro-degeneration of renal tubules, interstitial inflammatory cells, and a small number of lymphoma cells in the sub-capsule, compatible with acute interstitial nephritis. His renal dysfunction rapidly recovered following chemotherapy and combination antiretroviral therapy (cART). He developed pneumonia concomitantly with a decrease in HIV-RNA level and an increase in CD4+ cells after the first cycle of chemotherapy, which spontaneously resolved after the second cycle of chemotherapy without additional anti-infection drugs; thus, his pneumonia fulfilled the diagnostic criteria for IRIS. We suggest that IRIS may frequently develop during chemotherapy for HAL, but may be overlooked. He was coinfected with hepatitis B virus (HBV), which genotypes known as is associated with liver-related mortality and response to antiviral therapy; recently, an intimate interplay between HIV and HBV in the onset of lymphoma has been reported. Therefore, we addressed the HBV genotype in the patient. The analysis revealed that he exhibited a mixed genotype (A/E) not native to Japan and primarily found in Europe and North America or West Africa. These findings suggest that universal vaccination for juveniles against HBV is warranted in Japan.
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Affiliation(s)
- Katsushi Tajima
- Department of Radiation Emergency Medicine, National Institute of Radiological Sciences Chiba, Japan.
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Metz I, Radue EW, Oterino A, Kümpfel T, Wiendl H, Schippling S, Kuhle J, Sahraian MA, Gray F, Jakl V, Häusler D, Brück W. Pathology of immune reconstitution inflammatory syndrome in multiple sclerosis with natalizumab-associated progressive multifocal leukoencephalopathy. Acta Neuropathol 2012; 123:235-45. [PMID: 22057786 PMCID: PMC3259335 DOI: 10.1007/s00401-011-0900-5] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2011] [Revised: 10/16/2011] [Accepted: 10/24/2011] [Indexed: 11/01/2022]
Abstract
Natalizumab is an approved medication for highly active multiple sclerosis (MS). Progressive multifocal leukoencephalopathy (PML) may occur as a severe side effect of this drug. Here, we describe pathological and radiological characteristics of immune reconstitution inflammatory syndrome (IRIS), which occurs in natalizumab-associated PML after the cessation of therapy, and we differentiate it from ongoing PML. Brain biopsy tissue and MRI scans from five MS patients with natalizumab-associated PML were analyzed and their histology compared with non-MS PML. Histology showed an extensive CD8-dominated T cell infiltrate and numerous macrophages within lesions, and in nondemyelinated white and grey matter, in four out of five cases. Few or no virally infected cells were found. This was indicative of IRIS as known from HIV patients with PML. Outstandingly high numbers of plasma cells were present as compared to non-MS PML and typical MS lesions. MRI was compatible with IRIS, revealing enlarging lesions with a band-like or speckled contrast enhancement either at the lesion edge or within lesions. Only the fifth patient showed typical PML pathology, with low inflammation and high numbers of virally infected cells. This patient showed a similar interval between drug withdrawal and biopsy (3.5 months) to the rest of the cohort (range 2.5-4 months). MRI could not differentiate between PML-associated IRIS and ongoing PML. We describe in detail the histopathology of IRIS in natalizumab-associated PML. PML-IRIS, ongoing PML infection, and MS exacerbation may be impossible to discern clinically alone. MRI may provide some clues for distinguishing different pathologies that can be differentiated histologically. In our individual cases, biopsy helped to clarify diagnoses in natalizumab-associated PML.
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Affiliation(s)
- Imke Metz
- Department of Neuropathology, University Medical Center, Georg August University Göttingen, Germany.
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Abstract
After 30 years of the human immunodeficiency virus (HIV) epidemic, parasites have been one of the most common opportunistic infections (OIs) and one of the most frequent causes of morbidity and mortality associated with HIV-infected patients. Due to severe immunosuppression, enteric parasitic pathogens in general are emerging and are OIs capable of causing diarrhoeal disease associated with HIV. Of these, Cryptosporidium parvum and Isospora belli are the two most common intestinal protozoan parasites and pose a public health problem in acquired immunodeficiency syndrome (AIDS) patients. These are the only two enteric protozoan parasites that remain in the case definition of AIDS till today. Leishmaniasis, strongyloidiasis and toxoplasmosis are the three main opportunistic causes of systemic involvements reported in HIV-infected patients. Of these, toxoplasmosis is the most important parasitic infection associated with the central nervous system. Due to its complexity in nature, toxoplasmosis is the only parasitic disease capable of not only causing focal but also disseminated forms and it has been included in AIDS-defining illnesses (ADI) ever since. With the introduction of highly active anti-retroviral therapy (HAART), cryptosporidiosis, leishmaniasis, schistosomiasis, strongyloidiasis, and toxoplasmosis are among parasitic diseases reported in association with immune reconstitution inflammatory syndrome (IRIS). This review addresses various aspects of parasitic infections in term of clinical, diagnostic and therapeutic challenges associated with HIV-infection.
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Affiliation(s)
- Veeranoot Nissapatorn
- Department of Parasitology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
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Costello DJ, Gonzalez RG, Frosch MP. Case records of the Massachusetts General Hospital. Case 18-2011. A 35-year-old HIV-positive woman with headache and altered mental status. N Engl J Med 2011; 364:2343-52. [PMID: 21675893 DOI: 10.1056/nejmcpc1007104] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Daniel J Costello
- Department of Neurology, Massachusetts General Hospital, and the Harvard Medical School, Boston, USA
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Trindade MAB, Benard G, Ura S, Ghidella CC, Avelleira JCR, Vianna FR, Marques AB, Naafs B, Fleury RN. Granulomatous reactivation during the course of a leprosy infection: reaction or relapse. PLoS Negl Trop Dis 2010; 4:e921. [PMID: 21200422 PMCID: PMC3006134 DOI: 10.1371/journal.pntd.0000921] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2010] [Accepted: 11/18/2010] [Indexed: 11/19/2022] Open
Abstract
Background Leprosy is a chronic granulomatous infectious disease and is still endemic in many parts of the world. It causes disabilities which are the consequence of nerve damage. This damage is in most cases the result of immunological reactions. Objectives To investigate the differences between a type 1 leprosy (reversal) reaction and relapse on using histopathology. Methods The histopathological changes in 167 biopsies from 66 leprosy patients were studied. The patients were selected when their sequential biopsies demonstrated either different patterns or maintained the same pattern of granulomatous reaction over more than two years during or after the treatment of leprosy. Results In 57 of the patients studied, a reactivation was seen which coincided with a decrease in the bacteriological index (BI), suggesting that this reactivation (reversal reaction or type 1 leprosy reaction) coincides with an effective capacity for bacteriological clearance. In nine patients, an increase of the bacteriologic index (IB) or persistence of solid bacilli occurred during the reactivation, indicating proliferative activity, suggestive of a relapse. The histopathological aspects of the granulomas were similar in both groups. Conclusion Bacterioscopy provided the only means to differentiate a reversal reaction from a relapse in patients with granulomatous reactivation. The type 1 leprosy reaction may be considered as a part effective immune reconstitution (reversal, upgrading reaction) or as a mere hypersensitivity reaction (downgrading reaction) in a relapse. Leprosy is a serious infectious disease whose treatment still poses some challenges. Patients are usually treated with a combination of antimicrobial drugs called multidrug therapy. Although this treatment is effective against Mycobacterium leprae, the bacillus that causes leprosy, patients may develop severe inflammatory reactions during treatment. These reactions may be either attributed to an improvement in the immunological reactivity of the patient along with the treatment, or to relapse of the disease due to the proliferation of remaining bacilli. In certain patients these two conditions may be difficult to differentiate. The present study addresses the histopathology picture of and the M. leprae bacilli in sequential biopsies taken from lesions of patients who presented such reactions aiming to improve the differentiation of the two conditions. This is important because these reactions are one of the major causes of the disabilities of the patients with leprosy, and should be treated early and appropriately. Our results show that the histopathology picture alone is not sufficient, and that bacilli's counting is necessary.
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Boulware DR, Bonham SC, Meya DB, Wiesner DL, Park GS, Kambugu A, Janoff EN, Bohjanen PR. Paucity of initial cerebrospinal fluid inflammation in cryptococcal meningitis is associated with subsequent immune reconstitution inflammatory syndrome. J Infect Dis 2010; 202:962-70. [PMID: 20677939 PMCID: PMC2924457 DOI: 10.1086/655785] [Citation(s) in RCA: 151] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Cryptococcal meningitis (CM)-related immune reconstitution inflammatory syndrome (IRIS) complicates antiretroviral therapy (ART) in 20%-40% of ART-naive persons with AIDS and prior CM. Pathogenesis is unknown. METHODS We compared initial cerebrospinal fluid (CSF) cultures, inflammatory markers, and cytokine profiles in ART-naive patients with AIDS who did or did not subsequently develop IRIS after starting ART. We also compared results obtained at IRIS events or CM relapse. RESULTS Of 85 subjects with CM, 33 (39%) developed CM-related IRIS and 5 (6%) developed culture-positive CM relapse. At CM diagnosis, subjects subsequently developing IRIS had less inflammation, with decreased CSF leukocytes, protein, interferon-gamma, interleukin-6, interleukin-8, and tumor necrosis factor-alpha, compared with subjects not developing IRIS (P<.05, for each). Initial CSF white blood cell counts < or =25 cells/microL and protein levels < or =50 mg/dL were associated with development of IRIS (odds ratio, 7.2 [95% confidence interval, 2.7-18.7]; P<.001). Compared with baseline levels, we identified CSF elevations of interferon-gamma, tumor necrosis factor-alpha, granulocyte colony-stimulating factor, vascular-endothelial growth factor, and eotaxin (CCL11) (P<.05, for each) at the time of IRIS but minimal inflammatory changes in those with CM relapse. CONCLUSIONS Patients who subsequently develop CM-related IRIS exhibit less initial CSF inflammation at the time of CM diagnosis, compared with those who do not develop IRIS. The inflammatory CSF cytokine profiles observed at time of IRIS can distinguish IRIS from CM relapse.
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Affiliation(s)
- David R Boulware
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA.
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Cabral RF, Valle Bahia PR, Gasparetto EL, Chimelli L. Immune reconstitution inflammatory syndrome and cerebral toxoplasmosis. AJNR Am J Neuroradiol 2010; 31:E65-6. [PMID: 20507930 DOI: 10.3174/ajnr.a2158] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Reyes-Corcho A, Bouza-Jiménez Y. Critically Ill hiv-infected patients: the particular case of tuberculosis-associated immune reconstitution inflammatory syndrome. Clin Infect Dis 2009; 49:1773-4. [PMID: 19891571 DOI: 10.1086/648118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Jazwinski A, Naggie S, Perfect J. Immune reconstitution syndrome in a patient with disseminated histoplasmosis and steroid taper: maintaining the perfect balance. Mycoses 2009; 54:270-2. [PMID: 19843232 DOI: 10.1111/j.1439-0507.2009.01796.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Immune reconstitution syndrome (IRS) is an increasingly common condition that has been described in immunosuppressed individuals once immune function is restored. In this case, we describe a patient who had a renal transplant and subsequently developed pulmonary histoplasmosis. His course was also complicated by the development of a clinical syndrome that was originally attributed to thrombocytopenic thrombotic purpura (TTP). When he did not improve with plasmapheresis and high dose prednisone, a bone marrow biopsy revealed disseminated histoplasmosis and administration of prednisone was rapidly tapered. While on 5 mg of prednisone, he developed an inflammatory syndrome characterised by haemoptysis and respiratory distress, full work-up with pathology was consistent with immune reconstitution syndrome. Treatment for IRS consists of continuing treatment for the underlying infection and consideration of administering anti-inflammatory medication for supportive care. This syndrome should be considered in patients who develop worsening inflammatory symptoms while receiving appropriate treatment for their fungal infection in the setting of restoration of immune function.
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Biagetti C, Nicola M, Borderi M, Pavoni M, Tampellini L, Verucchi G, Chiodo F. Paradoxical immune reconstitution inflammatory syndrome associated with previous Cryptococcus neoformans infection in an HIV-positive patient requiring neurosurgical intervention. New Microbiol 2009; 32:209-212. [PMID: 19579702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Immune reconstitution inflammatory syndrome (IRIS) in HIV-1-infected patients is associated with an exaggerated inflammatory response against an opportunistic infection during highly active antiretroviral therapy. The only review on IRIS associated with Criptococcus neoformans reported 21 episodes including lymphadenitis, necrotizing pneumonitis, breast and cutaneous abscess, and cryptococcomas. To our knowledge this is the first report of IRIS associated with previous meningeal criptococcal infection which required neurosurgical intervention with placement of a ventriculo-peritoneal shunt to drain a CSF cyst formed by exclusion of the temporal horn of the right lateral ventricle. We demonstrate that this procedure is possible without complications such as cryptococcal dissemination into the peritoneum.
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Affiliation(s)
- Carlo Biagetti
- Department of Digestive Apparatus Disease and Internal Medicine, Section of Infectious Diseases, "Alma Mater Studiorum", University of Bologna, S. Orsola Hospital, Bologna, Italy.
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Iarikov D, Duke W, Skiest D. Extensive development of flat warts as a cutaneous manifestation of immune reconstitution syndrome. AIDS Read 2008; 18:524-527. [PMID: 18975443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Cutaneous manifestations of immune recovery in response to highly active antiretroviral therapy may account for up to 54% to 78% of the clinical presentations of the immune reconstitution syndrome (IRS). Genital herpes, varicella-zoster virus infection, genital warts, and molluscum contagiosum represent the majority of these cutaneous manifestations. Inflammation of preexisting cutaneous warts in response to effective antiretroviral therapy has rarely been described. We report the case of sudden extensive development of cutaneous warts, specifically verruca plana confirmed by skin biopsy, observed following antiretroviral therapy-associated immune reconstitution in a patient without a history of warts. The possibility of cutaneous IRS after commencement of antiretroviral therapy should be considered in a patient with unusual skin manifestations.
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Affiliation(s)
- Dmitri Iarikov
- Baystate Medical Center, Tufts University School of Medicine, Springfield, Massachusetts, USA
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