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immune reconstitution inflammatory syndrome (IRIS)

Etiology: - immunological recovery after administration of HAART in AIDS patients - inflammatory response to pre-existing infection - associated with disseminated Mycobacterium avium complex, tuberculosis, disseminated mycosis, CMV & Herpes zoster - meningitis most likely a result of Cryptococcus neoformans [1] Epidemiology: - occurs in a small subset of patients treated with highly-active antiretroviral therapy (HAART) Pathology: - inflammatory response to previously unrecognized opportunistic infection(s) when a rejuvinated immune system reacts to a high burden of antigen(s) - thyrotoxicosis due to Graves disease Clinical manifestations: 1) fever 2) lymphadenopathy 3) may occur a few weeks to a few months after initiation of antiretroviral therapy 4) robust inflammatory response to opportunistic infection 5) thyrotoxicosis generally occurs later than inflammatory response to opportunistic infection Laboratory: - CD4 count: - IRS may occur with CD4 count of 56/uL [1] - case of IRIS with CD4 count of 256/uL at time of HIV1 diagnosis - HIV1 viral load: (IRIS may occur with HIV1 viral load of 5140 copies/mL) [1] - thyroid function testing as indicated Management: - delay in initiating HAART in AIDS patients (CD4 count < 50/uL) with tuberculosis - begin treatment of tuberculosis 2 weeks prior to initiating HAART [1] - once initiated, continue antiretroviral therapy (HAART) during IRIS [1] - systemic glucocorticoid may moderate excessive inflammatory response [1] - referral recommended for management of thyrotoxicosis due to Graves disease [4]

Related

iris of the eye (orris, I)

General

syndrome complications in patients with HIV1 infection

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 14, 15 16, 17, 18. American College of Physicians, Philadelphia 2006, 2009, 2012, 2015, 2018. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  2. Letendre SL, Ellis RJ, Everall I et al Neurologic complications of HIV disease and their treatment. Top HIV Med. 2009 Apr-May;17(2):46-56. PMID: 19401607
  3. Jubault V, Penfornis A, Schillo F et al Sequential occurrence of thyroid autoantibodies and Graves' disease after immune restoration in severely immunocompromised human immunodeficiency virus-1-infected patients. J Clin Endocrinol Metab. 2000 Nov;85(11):4254-7. PMID: 11095463
  4. Muller I, Moran C, Lecumberri B et al 2019 European Thyroid Association Guidelines on the Management of Thyroid Dysfunction following Immune Reconstitution Therapy. Eur Thyroid J. 2019 Jul;8(4):173-185. PMID: 31602359 PMCID: PMC6738237 Free PMC article. Review.