Immune reconstitution syndrome

Immune Reconstitution Inflammatory Syndrome (IRIS) is a condition seen in some patients who have advanced immunodeficiency diseases and who start antiretroviral therapy (ART). IRIS results from the rapid improvement in immune function, leading to either the unmasking of previously undiagnosed infections or an exaggerated inflammatory response to a known infection.

Etiology

IRIS is primarily associated with HIV patients who begin ART. The syndrome can manifest in two main forms: unmasking IRIS, where a previously undetected opportunistic infection becomes apparent following immune recovery, and paradoxical IRIS, where there is a worsening of a known infection's clinical presentation after starting ART. Other conditions, such as the initiation of antimicrobial therapy in tuberculosis (TB) and other opportunistic infections, can also trigger IRIS in individuals with or without HIV.

Pathophysiology

The pathogenesis of IRIS is not fully understood but is thought to involve the rapid restoration of pathogen-specific immune responses. This leads to an exaggerated inflammatory response against existing opportunistic pathogens. The syndrome typically occurs within days to months after initiating ART in HIV patients or other forms of immune restoration.

Clinical Manifestations

The clinical presentation of IRIS varies widely depending on the underlying opportunistic infection involved. Common manifestations include fever, lymphadenopathy, skin lesions, and respiratory symptoms. In cases of paradoxical IRIS, patients may experience a worsening of symptoms associated with the underlying infection, such as more severe respiratory symptoms in TB or neurological symptoms in cryptococcal meningitis.

Diagnosis

Diagnosis of IRIS is challenging as there are no specific tests. It is primarily a diagnosis of exclusion, based on the temporal relationship between the initiation of immune restoration therapy and the onset of symptoms, along with the exclusion of other causes for clinical deterioration, such as drug resistance or treatment failure.

Management

Management of IRIS involves the treatment of the underlying opportunistic infection, along with supportive care. In severe cases, corticosteroids may be used to reduce inflammation. Continuation of ART is generally recommended, although temporary interruption may be considered in life-threatening cases.

Prevention

Preventive strategies for IRIS include the early diagnosis and treatment of HIV and opportunistic infections before the initiation of ART. In patients with a high risk of developing IRIS, careful monitoring after starting ART or immune restoration therapy is essential.

Prognosis

The prognosis of IRIS varies depending on the severity of the inflammatory response and the opportunistic infection involved. With appropriate treatment, most patients recover fully, although severe cases can be life-threatening.

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See Also

• Antiretroviral therapy
• Opportunistic infection
• HIV/AIDS
• Tuberculosis

References

External Links

• World Health Organization (WHO)
• Centers for Disease Control and Prevention (CDC)