The management of corticosteroid refractory immune reconstitution inflammatory syndrome (IRIS) is currently unclear. Infliximab administration was associated with clinical improvement without significant adverse events in 3 patients with mycobacterial IRIS. Immunologic and virologic responses to antiretroviral therapy were unaffected. Tumor necrosis factor blockade may be beneficial for IRIS and warrants further study in clinical trials.

BackgroundAppendicitis occurs with increased frequency in HIV infected compared to HIV uninfected persons. CMV-related appendicitis specifically presents with typical appendicitis symptoms including surgical abdomen, fever and leukocytosis and may have a more severe course with higher mortality than other types of infective appendicitis. We report the first case of CMV appendicitis as a manifestation of Immune Reconstitution Inflammatory Syndrome (IRIS).Case presentationThe patient was a 38 year old woman with a recent diagnosis of HIV infection who complained of right lower quadrant pain, anorexia, nausea and fevers two weeks after initiating antiretroviral therapy. Acute appendicitis was suspected and the patient underwent an appendectomy. Pathologic examination of the resected appendiceal tissue demonstrated inflammation with perforation and cytopathic changes typical of CMV that were positive for CMV by immunostain. This presentation of CMV abruptly after antiretroviral therapy initiation with a pronounced cellular infiltration of the tissue, is consistent with CMV-IRIS presenting as appendicitis.ConclusionsAppendicitis can be a rare manifestation of CMV-IRIS in HIV-infected patients who start antiretroviral therapy. Evaluation of appendiceal tissue for cytopathic changes and CMV should be considered in acute appendicitis in HIV infected persons.

The objective of this study was to assess the water collection, treatment, and contamination in Upper and Lower Belén neighborhoods of Iquitos, Peru to address the longstanding prevalence of waterborne disease. Fifty household surveys were performed and 45 water samples were analyzed for fecal coliforms (FC). Most drinking water was untreated at home and negative for FC. Of the FC-positive waters (11.1%), the source was Sedaloreto tap water, the municipally owned water company and treatment facility. No FC-positive samples resulted from residences reporting home treatment. This suggests sufficient sterilization at the point of treatment but contamination within the distribution system or individual homes. Therefore, it is critical to emphasize the importance of home-based treatment until the distribution system can be reliable. Although the prevalence of FC-positive samples were similar in Upper and Lower Belén, residents in Lower Belén remain at increased risk for waterborne disease due to seasonal environmental conditions such as flooding and the lack of home sanitation facilities.