Immune reconstitution inflammatory syndrome: Difference between revisions
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===Major Presentations=== | ===Major Presentations=== | ||
*[[TB]]- worsening TB symptoms | *[[TB]]- worsening TB symptoms | ||
*MAC- localized lymphadenitis, pulmonary disease, systemic inflammation indistinguishable from active MAC | *[[mycobacterium avium|MAC]]- localized [[lymphadenitis]], pulmonary disease, systemic inflammation indistinguishable from active MAC | ||
**MAC-IRIS patients are not bacteremic | **MAC-IRIS patients are not bacteremic | ||
*[[Cryptococcosis]]- worsening meningitis symptoms | *[[Cryptococcosis]]- worsening meningitis symptoms | ||
*[[CMV]]- | *[[CMV]]- [[CMV retinitis|retinitis]], vitritis, [[uveitis]] | ||
**IRIS due to CMV can cause vision loss | **IRIS due to CMV can cause vision loss | ||
***mean time to vitritis 20 weeks | ***mean time to vitritis 20 weeks | ||
*[[Hepatitis]] B or C- transient transaminitis difficult to distinguish from drug induced cause | *[[viral hepatitis|Hepatitis]] B or C- transient transaminitis difficult to distinguish from drug induced cause | ||
**hepatic flares usually mild, may decompensate cirrhotics. | **hepatic flares usually mild, may decompensate cirrhotics. | ||
*[[Progressive multifocal leukoencephalopathy]]- worsening focal neuro lesions, changes on MRI | *[[Progressive multifocal leukoencephalopathy]]- worsening focal neuro lesions, changes on [[brain MRI|MRI]] | ||
*[[Kaposi's Sarcoma]]- worsening Kaposi's | *[[Kaposi's Sarcoma]]- worsening Kaposi's | ||
*Autoimmune diseases- Pre-existing autoimmune disorder exacerbation | *Autoimmune diseases- Pre-existing autoimmune disorder exacerbation | ||
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==Differential Diagnosis== | ==Differential Diagnosis== | ||
*New infection not associated with IRIS (i.e. bacterial meningitis) | *New infection not associated with IRIS (i.e. bacterial [[meningitis]]) | ||
*Opportunistic | *Opportunistic [[infection]] | ||
{{HIV associated conditions}} | {{HIV associated conditions}} | ||
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==Evaluation== | ==Evaluation== | ||
*Index of suspicion with known recent initiation of ARV's | *Index of suspicion with known recent initiation of ARV's | ||
*System specific testing (CXR, LP etc) | *System specific testing ([[CXR]], [[LP]] etc) | ||
==Management== | ==Management== | ||
===Mild IRIS=== | ===Mild IRIS=== | ||
*Standard therapy for offending opportunistic info (i.e. acyclovir for HSV) | *Standard therapy for offending opportunistic info (i.e. [[acyclovir]] for HSV) | ||
*Largely supportive care | *Largely supportive care | ||
** | **[[NSAIDs]] for mild symptoms | ||
**Inhaled steroids for pulmonary symptoms | **[[Inhaled steroids]] for pulmonary symptoms | ||
*Continue ARV except in severe IRIS (see below) | *Continue ARV except in severe IRIS (see below) | ||
Latest revision as of 01:17, 2 October 2019
Background
- Also called IRIS
- Definition-Disease or pathogen specific inflammatory response in HIV infected patients after initiation or re-initiation of ARV therapy or after change to more active ARV therapy.
- Usually low CD4 counts and high viral loads at time of ARV initiation
- Can occur at any CD4 count
- Occurs usually within 4-8 weeks after initiation of therapy
Clinical Features
Major Presentations
- TB- worsening TB symptoms
- MAC- localized lymphadenitis, pulmonary disease, systemic inflammation indistinguishable from active MAC
- MAC-IRIS patients are not bacteremic
- Cryptococcosis- worsening meningitis symptoms
- CMV- retinitis, vitritis, uveitis
- IRIS due to CMV can cause vision loss
- mean time to vitritis 20 weeks
- IRIS due to CMV can cause vision loss
- Hepatitis B or C- transient transaminitis difficult to distinguish from drug induced cause
- hepatic flares usually mild, may decompensate cirrhotics.
- Progressive multifocal leukoencephalopathy- worsening focal neuro lesions, changes on MRI
- Kaposi's Sarcoma- worsening Kaposi's
- Autoimmune diseases- Pre-existing autoimmune disorder exacerbation
Minor Presentations
- Herpes Simplex Virus and Varicella zoster virus reactivation
- Non-specific derm- many including oral and genital warts
Differential Diagnosis
- New infection not associated with IRIS (i.e. bacterial meningitis)
- Opportunistic infection
HIV associated conditions
- HIV neurologic complications
- HIV pulmonary complications
- Ophthalmologic complications
- Other
- HAART medication side effects[1]
- HAART-induced lactic acidosis
- Neuropyschiatric effects
- Hepatic toxicity
- Renal toxicity
- Steven-Johnson's
- Cytopenias
- GI symptoms
- Endocrine abnormalities
Evaluation
Management
Mild IRIS
- Standard therapy for offending opportunistic info (i.e. acyclovir for HSV)
- Largely supportive care
- NSAIDs for mild symptoms
- Inhaled steroids for pulmonary symptoms
- Continue ARV except in severe IRIS (see below)
Severe IRIS
- Defined as a threat to functional status or permanent disability (i.e. vision loss from CMV)
- Severe IRIS- prednisone 1-2mg/kg (consult HIV/ID) for 1-2 weeks then taper
Disposition
- Admit for severe IRIS.
- Dispo in conjunction with HIV/ID consult.
See Also
External Links
- www.hivguidelines.org
References
- ↑ Gutteridge, David L MD, MPH, Egan, Daniel J. MD. The HIV-Infected Adult Patient in The Emergency Department: The Changing Landscape of the Disease. Emergency Medicine Practice: An Evidence-Based Approach to Emergency Medicine. Vol 18, Num 2. Feb 2016.