We need you! Join our contributor community and become a WikEM editor through our open and transparent promotion process.
Immune reconstitution inflammatory syndrome
From WikEM
Contents
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
- AIDS fever of unknown origin
- Immune reconstitution inflammatory syndrome
- HIV diarrhea
- Kaposi's sarcoma
- Pruritic papular eruption of HIV
- HAART medication side effects[1]
- Lactic acidosis
- Neuropyschiatric effects
- Hepatic toxicity
- Renal toxicity
- Steven-Johnson's
- Cytopenias
- GI symptoms
- Endocrine abnormalities
Evaluation
- Index of suspicion with known recent initiation of ARV's
- System specific testing (CXR, LP etc)
Management
Mild IRIS
- Standard therapy for offending opportunistic info (i.e. acyclovir for HSV)
- Largely supportive care
- NSAID's 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.
