Cryptococcal meningitis immune reconstitution syndrome in an adolescent infected with HIV
Keywords:
IMMUNE RECONSTITUTION INFLAMMATORY SYNDROME, CRYPTOCOCCAL MENINGITIS, HIV
Abstract
Immune reconstitution inflammatory syndrome (IRIS) is a complication of HIV (Human Immunodeficiency Virus) in patients who previously had a deep alteration in their immune system.
Two forms of clinical presentation are recognized: unmasking and paradoxical IRIS.
We present the case of a 13 year old adolescent who is diagnosed with HIV and whose source of infection transmission could not be established.
At the time of diagnosis, antiretroviral treatment is initiated under severe immunosuppression, and within two months she is admitted to hospital for a cryptococcal meningitis.
Treated with amphotericin, the patient evidences a positive evolution and it was possible to sterilize the spinal fluid. Once again, the patient presents intracranial hypertension with signs of meningeal irritation and seizures. She is transferred to the ICU and treated with high dose corticoids. Upon improvement, the patient is discharged from hospital.
The first episode is interpreted as unmasking IRIS cryptococcal meningitis. That is, viable germs stood out in spite of failure to recognize their presence.
The second episode is interpreted as a paradoxical IRIS. The fact that it previously had sterile spinal fluid and improved with corticoids and without antifungal treatment confirms diagnosis.
Presumed IRIS is diagnosed upon absence of certain diagnostic elements. The clinical data correspond to an immunosuppressed HIV patient, who is treated with high efficacy, what enables diagnosis.
References
(1) Sterne J, Hernan M, Ledergerber B, Tilling K, Weber R, Pedran M. Long-term effectiveness of potent antiretroviral therapy in preventing AIDS and death: a prospective cohort study. Lancet 2005; 366(9483):378-84.
(2) Autran B, Carcelain G, Li T, Blanc C, Mathez B, Tubiana R. Positive effects of combined antiretroviral therapy on CD4+T cell homeostasis and function in advanced HIV disease. Science 1997; 277(5322):112-6.
(3) Battegay M, Nüesch R, Hirschel B, Kaufmann G. Immunological recovery and antiretroviral therapy in HIV-1 infection. Lancet Infect Dis 2006; 6(5):280-7.
(4) Singh N, Perfect J. Immune reconstitution syndrome associated with opportunistic mycoses. Lancet Infect Dis 2007; 7(6):395-401.
(5) Shelburne SA 3rd, Hamill RJ, Rodriguez-Barradas MC, Greenberg SB, Atmar RL, Musher DW, et al. Immune reconstitution inflammatory syndrome: emergence of a unique syndrome during highly active antiretroviral therapy. Medicine (Baltimore) 2002; 81(3):213-27.
(6) French M, Price P, Stone S. Immune restoration disease after antiretroviral therapy. AIDS 2004; 18(12):1615-27.
(7) French MA, Mallal SA, Dawkins RL. Zidovudine-induced restoration of cell-mediated immunity to mycobacteria in immunodeficient HIV infected patients. AIDS 1992; 6(11):1293-7.
(8) French M. HIV/AIDS: immune reconstitution inflammatory syndrome: a repraisal Clin Infect Dis 2009; 48(1):101-7.
(9) Singh N, Lortholary O, Alexander BD, Gupta KL, John GT, Pursell K, et al. An immune reconstitution syndrome-like illness associated with Cryptococcus neoformans infection infection in organ transplant recipients. Clin Infect Dis 2005; 40(12):1756-61.
(10) Cheng VC, Yuen KY, Wong SS, Woo PC, Ho PL, Lee R, et al. Immunorestitution diseases in patients no infected with HIV. Eur J Clin Microbiol Infect Dis 2001; 20(6):402-6.
(11) Einsiedel L, Gordon DL, Dyer JR. Paradoxical inflammatory reaction during treatment of Cryptococcus neoformans var.gatii meningitis in an HIV- seronegative woman. Clin Infect Dis 2004; 39(8):e78-82.
(12) Bower M, Nelson M, Young AM, Thirlwell C, Newsom-Davis T, Mandalia S, et al. Immune reconstitution syndrome associated with Kaposi`s sarcoma. J Clin Oncol 2005; 23(22):5224-8.
(13) Kumarasamy N, Chaguturu S, Mayer KH, Solomon S, Yepthomi HT, Balakrishnan P, et al. Incidence of immune reconstitution syndrome in HIV/tuberculosis-coinfected patients after initiation of generic antiretroviral therapy in India. J Acquir Immune Defic Syndr 2004; 37(5):1574-6.
(14) Narita M, Ashkin D, Hollender ES, Pitchenik AE. Paradoxical worsening of tuberculosis following therapy in patients with AIDS. Am J Respir Crit Care Med 1998; 158(1):157-61.
(15) John L, Baalwa J, Kalimugogo P, Nabankema E, Castelnuovo B, Muhindo G, et al. Response to "Does immune reconstitution promote active tuberculosis in patients receiving highly active antiretroviral therapy?". AIDS 2005; 19(17):2049-50.
(16) French MA, Lenzo N, John M, Mallal SA, McKinnon EJ, James IR, et al. Immune restoration disease after the treatment of immunodeficient HIV- infected patients with highly active antiretroviral therapy. HIV Med 2000; 1(2):107-15.
(17) Jevtoviæ DJ, Salemoviæ D, Ranin J, Pesiæ I, Zerjav S, Djurkoviæ-Djakoviæ O. The prevalence and risk of immune restoration disease in HIV-infected patients treated with highly active antiretroviral therapy. HIV Med 2005; 6(2):140-5.
(18) Bourgarit A, Carcelain G, Martinez V, Lascoux C, Delcey V, Gicquel B, et al. Explosion of tuberculin-specific Th1-responses induces immune restoration syndrome in tuberculosis and HIV co-infected patients. AIDS 2006; 20(2):F1-7.
(19) Shelburne SA 3rd, Darcourt J, White AC Jr, Greenberg SB, Hamill RJ, Atmar RL, et al. The role of immune reconstitution inflammatory syndrome in AIDS-related Cryptococcus Neoformans disease in the era of highly active antiretroviral therapy. Clin Infect Dis 2005; 40(7):1049-52.
(20) McCombe JA, Auer RN, Maingat FG, Houston S, Gill MJ, Power C. Neurologic immune reconstitution inflammatory syndrome in HIV/AIDS: outcome and epidemiology. Neurology 2009; 72(9):835-41.
(21) Asselman V, Thienemann F, Pepper DJ, Boulle A, Wilkinson RJ, Meintjes G, et al. Central nervous system disorders after starting antiretroviral therapy in South Africa. AIDS 2010; 24(18):2871-6.
(22) Puthanakit T, Oberdorfer P, Akarathum N, Wannarit P, Sirisanthana T, Sirisanthana V. Immune reconstitution syndrome after highly active antiretroviral therapy in HIV-infected thai children. Pediatr Infect Dis J 2006; 25(1):53-8.
(23) Tangsinmankong N, Kamchaisatian W, Lujan-Zilbermann J, Brown CL, Sleasman JW, Emmanuel PJ. Varicella zoster as a manifestation of immune restoration disease in HIV-infected children. J Allergy Clin Immunol 2004; 113(4):742-6.
(24) Johnson T, Nath A. Immune reconstitution inflammatory syndrome and the central nervous system. Curr Opin Neurol 2011; 24(3):284-90.
(25) Müller M, Wandel S, Colebunders R, Attia S, Furrer H, Egger M, et al. Immune reconstitution inflamatory syndrom in patients starting antiretroviral therapy for HIV infection: a systematic review and meta-analysis. Lancet Infect Dis 2010; 10(4):251-61.
(26) Price P, Morahan G, Huang D, Stone E, Cheong KY, Castley A, et al. Polymorphisms in cytokine genes define subpopulations of HIV-1 patients who experienced immune restoration diseases. AIDS 2002; 16(15):2043-7.
(27) Price P, Keane NM, Stone SF, Cheong KY, French MA. MHC haplotyoes affect the expression of opportunistic infections in HIV patients. Hum Immunol 2001; 62(2):157-64.
(28) Singh N, Perfect JR. Immune reconstitution syndrome associated with opportunistic mycoses. Lancet Infect Dis 2007; 7(6):395-401.
(29) Lortholary O, Fontanet A, Mémain N, Martin A, Sitbon K, Dromer F, et al. Incidence and risk factors of immune reconstitution inflamatory syndrome complicating HIV-associated cryptococcosis in France. AIDS 2005; 19(10):1043-9.
(30) Mofenson LM, Brady MT, Danner SP, Dominguez KL, Hazra R, Handelsman E, et al. Guidelines for the Prevention and Treatment of Opportunistic Infections among HIV-exposed and HIV-infected children: recommendations from CDC, the National Institutes of Health, the HIV Medicine Association of the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the American Academy of Pediatrics. MMWR Recomm Rep 2009; 58(RR-11):1-166.
(31) World Health Organization. Rapid advice: diagnosis, prevention and management of cryptococcal disease in HIV-infected adults, adolescents and children. Geneva: WHO, 2011. Disponible en: http://www.who.int/hiv/pub/cryptococcal_disease2011/en/. Consulta: 13 diciembre2011
(32) Quian J, Picón T, Galazka J, Gutiérrez S, Cafferata ML, Rodríguez I, et al. Síndrome de Inmunodeficiencia Adquirida en niños. Formas graves de enfermedad por BCG. Rev enfermedades infecc ped 2000; 14(54):62-7.
(33) Hesseling AC, Marais BJ, Gie RP, Schaaf HS, Fine PE, Godfrey-Faussett P, et al. The risk of disseminated Bacille Calmette-Guérin (BCG) disease in HIV-infected children. Vaccine 2007; 25(1):14-8.
(34) Hesseling AC, Rabie H, Marais BJ, Manders M, Lips M, Schaaf HS, et al. Bacille Calmette-Guérin vaccine-induced disease in HIV-infected an HIV- uninfected children. Clin Infect Dis 2006; 42(4):548-58.
(2) Autran B, Carcelain G, Li T, Blanc C, Mathez B, Tubiana R. Positive effects of combined antiretroviral therapy on CD4+T cell homeostasis and function in advanced HIV disease. Science 1997; 277(5322):112-6.
(3) Battegay M, Nüesch R, Hirschel B, Kaufmann G. Immunological recovery and antiretroviral therapy in HIV-1 infection. Lancet Infect Dis 2006; 6(5):280-7.
(4) Singh N, Perfect J. Immune reconstitution syndrome associated with opportunistic mycoses. Lancet Infect Dis 2007; 7(6):395-401.
(5) Shelburne SA 3rd, Hamill RJ, Rodriguez-Barradas MC, Greenberg SB, Atmar RL, Musher DW, et al. Immune reconstitution inflammatory syndrome: emergence of a unique syndrome during highly active antiretroviral therapy. Medicine (Baltimore) 2002; 81(3):213-27.
(6) French M, Price P, Stone S. Immune restoration disease after antiretroviral therapy. AIDS 2004; 18(12):1615-27.
(7) French MA, Mallal SA, Dawkins RL. Zidovudine-induced restoration of cell-mediated immunity to mycobacteria in immunodeficient HIV infected patients. AIDS 1992; 6(11):1293-7.
(8) French M. HIV/AIDS: immune reconstitution inflammatory syndrome: a repraisal Clin Infect Dis 2009; 48(1):101-7.
(9) Singh N, Lortholary O, Alexander BD, Gupta KL, John GT, Pursell K, et al. An immune reconstitution syndrome-like illness associated with Cryptococcus neoformans infection infection in organ transplant recipients. Clin Infect Dis 2005; 40(12):1756-61.
(10) Cheng VC, Yuen KY, Wong SS, Woo PC, Ho PL, Lee R, et al. Immunorestitution diseases in patients no infected with HIV. Eur J Clin Microbiol Infect Dis 2001; 20(6):402-6.
(11) Einsiedel L, Gordon DL, Dyer JR. Paradoxical inflammatory reaction during treatment of Cryptococcus neoformans var.gatii meningitis in an HIV- seronegative woman. Clin Infect Dis 2004; 39(8):e78-82.
(12) Bower M, Nelson M, Young AM, Thirlwell C, Newsom-Davis T, Mandalia S, et al. Immune reconstitution syndrome associated with Kaposi`s sarcoma. J Clin Oncol 2005; 23(22):5224-8.
(13) Kumarasamy N, Chaguturu S, Mayer KH, Solomon S, Yepthomi HT, Balakrishnan P, et al. Incidence of immune reconstitution syndrome in HIV/tuberculosis-coinfected patients after initiation of generic antiretroviral therapy in India. J Acquir Immune Defic Syndr 2004; 37(5):1574-6.
(14) Narita M, Ashkin D, Hollender ES, Pitchenik AE. Paradoxical worsening of tuberculosis following therapy in patients with AIDS. Am J Respir Crit Care Med 1998; 158(1):157-61.
(15) John L, Baalwa J, Kalimugogo P, Nabankema E, Castelnuovo B, Muhindo G, et al. Response to "Does immune reconstitution promote active tuberculosis in patients receiving highly active antiretroviral therapy?". AIDS 2005; 19(17):2049-50.
(16) French MA, Lenzo N, John M, Mallal SA, McKinnon EJ, James IR, et al. Immune restoration disease after the treatment of immunodeficient HIV- infected patients with highly active antiretroviral therapy. HIV Med 2000; 1(2):107-15.
(17) Jevtoviæ DJ, Salemoviæ D, Ranin J, Pesiæ I, Zerjav S, Djurkoviæ-Djakoviæ O. The prevalence and risk of immune restoration disease in HIV-infected patients treated with highly active antiretroviral therapy. HIV Med 2005; 6(2):140-5.
(18) Bourgarit A, Carcelain G, Martinez V, Lascoux C, Delcey V, Gicquel B, et al. Explosion of tuberculin-specific Th1-responses induces immune restoration syndrome in tuberculosis and HIV co-infected patients. AIDS 2006; 20(2):F1-7.
(19) Shelburne SA 3rd, Darcourt J, White AC Jr, Greenberg SB, Hamill RJ, Atmar RL, et al. The role of immune reconstitution inflammatory syndrome in AIDS-related Cryptococcus Neoformans disease in the era of highly active antiretroviral therapy. Clin Infect Dis 2005; 40(7):1049-52.
(20) McCombe JA, Auer RN, Maingat FG, Houston S, Gill MJ, Power C. Neurologic immune reconstitution inflammatory syndrome in HIV/AIDS: outcome and epidemiology. Neurology 2009; 72(9):835-41.
(21) Asselman V, Thienemann F, Pepper DJ, Boulle A, Wilkinson RJ, Meintjes G, et al. Central nervous system disorders after starting antiretroviral therapy in South Africa. AIDS 2010; 24(18):2871-6.
(22) Puthanakit T, Oberdorfer P, Akarathum N, Wannarit P, Sirisanthana T, Sirisanthana V. Immune reconstitution syndrome after highly active antiretroviral therapy in HIV-infected thai children. Pediatr Infect Dis J 2006; 25(1):53-8.
(23) Tangsinmankong N, Kamchaisatian W, Lujan-Zilbermann J, Brown CL, Sleasman JW, Emmanuel PJ. Varicella zoster as a manifestation of immune restoration disease in HIV-infected children. J Allergy Clin Immunol 2004; 113(4):742-6.
(24) Johnson T, Nath A. Immune reconstitution inflammatory syndrome and the central nervous system. Curr Opin Neurol 2011; 24(3):284-90.
(25) Müller M, Wandel S, Colebunders R, Attia S, Furrer H, Egger M, et al. Immune reconstitution inflamatory syndrom in patients starting antiretroviral therapy for HIV infection: a systematic review and meta-analysis. Lancet Infect Dis 2010; 10(4):251-61.
(26) Price P, Morahan G, Huang D, Stone E, Cheong KY, Castley A, et al. Polymorphisms in cytokine genes define subpopulations of HIV-1 patients who experienced immune restoration diseases. AIDS 2002; 16(15):2043-7.
(27) Price P, Keane NM, Stone SF, Cheong KY, French MA. MHC haplotyoes affect the expression of opportunistic infections in HIV patients. Hum Immunol 2001; 62(2):157-64.
(28) Singh N, Perfect JR. Immune reconstitution syndrome associated with opportunistic mycoses. Lancet Infect Dis 2007; 7(6):395-401.
(29) Lortholary O, Fontanet A, Mémain N, Martin A, Sitbon K, Dromer F, et al. Incidence and risk factors of immune reconstitution inflamatory syndrome complicating HIV-associated cryptococcosis in France. AIDS 2005; 19(10):1043-9.
(30) Mofenson LM, Brady MT, Danner SP, Dominguez KL, Hazra R, Handelsman E, et al. Guidelines for the Prevention and Treatment of Opportunistic Infections among HIV-exposed and HIV-infected children: recommendations from CDC, the National Institutes of Health, the HIV Medicine Association of the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the American Academy of Pediatrics. MMWR Recomm Rep 2009; 58(RR-11):1-166.
(31) World Health Organization. Rapid advice: diagnosis, prevention and management of cryptococcal disease in HIV-infected adults, adolescents and children. Geneva: WHO, 2011. Disponible en: http://www.who.int/hiv/pub/cryptococcal_disease2011/en/. Consulta: 13 diciembre2011
(32) Quian J, Picón T, Galazka J, Gutiérrez S, Cafferata ML, Rodríguez I, et al. Síndrome de Inmunodeficiencia Adquirida en niños. Formas graves de enfermedad por BCG. Rev enfermedades infecc ped 2000; 14(54):62-7.
(33) Hesseling AC, Marais BJ, Gie RP, Schaaf HS, Fine PE, Godfrey-Faussett P, et al. The risk of disseminated Bacille Calmette-Guérin (BCG) disease in HIV-infected children. Vaccine 2007; 25(1):14-8.
(34) Hesseling AC, Rabie H, Marais BJ, Manders M, Lips M, Schaaf HS, et al. Bacille Calmette-Guérin vaccine-induced disease in HIV-infected an HIV- uninfected children. Clin Infect Dis 2006; 42(4):548-58.
Published
2012-09-30
How to Cite
1.
Quian J, Gutiérrez S, González V. Cryptococcal meningitis immune reconstitution syndrome in an adolescent infected with HIV. Rev. Méd. Urug. [Internet]. 2012Sep.30 [cited 2024Dec.18];28(3):215-20. Available from: https://www2.rmu.org.uy/ojsrmu311/index.php/rmu/article/view/343
Section
Clinical Cases
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
