CNS–Immune Reconstitution Inflammatory Syndrome in the Setting of HIV Infection, Part 2: Discussion of Neuro–Immune Reconstitution Inflammatory Syndrome with and without Other Pathogens

Abstract

SUMMARY While the previous review of CNS-IRIS in the HIV-infected patient on highly active antiretroviral therapy (Part 1) dealt with an overview of the biology, pathology, and neurologic presentation of this condition and a discussion of the atypical imaging findings in PML-IRIS and cryptococcal meningitis–IRIS due to the robust inflammatory response, the current review (Part 2) discusses the imaging findings in other commonly encountered organisms seen in association with CNS-IRIS, namely, VZV, CMV, HIV, Candida organisms, Mycobacterium tuberculosis, and Toxoplasma gondii. Also described is the imaging appearance of CNS-IRIS when not associated with a particular organism. Recognition of these imaging findings will give credence to the diagnosis of CNS-IRIS and will allow the clinician to institute changes in medical management, if necessary, so that immune reconstitution and improved patient outcome can occur with time.

Drug Induced Increases in CNS Dopamine Alter Monocyte, Macrophage and T Cell Functions: Implications for HAND

“…CNS-IRIS is a T cell-mediated encephalitis that occurs after partial to full restoration of the immune system in HIV infected individuals beginning cART. This hyperacute immune response can be initiated by opportunistic infections of the CNS (Woods et al 1998; Jenny-Avital and Abadi 2002; Tan et al 2009; Nelson and Zunt 2011; Tsambiras et al 2001; Martin-Blondel et al 2011; Post et al 2012a, b). These infections may have been present and treated in HIV infected individuals before their initiation of cART, resulting in an exacerbated immune response to residual infection upon reconstitution of the immune system.…”

“…In other individuals, an undetected opportunistic infection is unmasked after cART, but in many cases of CNS-IRIS there is no identifiable infectious pathogen. These cases may be due to an enhanced immune response directed against the HIV reservoir within the CNS, an autoimmune response directed against CNS proteins, or a nonspecific inflammatory response generated within the CNS (Post et al 2012b). …”

When smear and molecular diagnostics fail: identification of tuberculosis in advanced HIV infection using the newly developed urine lipoarabinomannan lateral-flow assay

“…The paradoxical progression of disease despite ART, or the development of new symptoms and signs, should raise a suspicion of IRIS 8. Up to 43% of patients dually infected with TB and HIV and who are on anti-TB and ART develop IRIS 9. Although IRIS is a common diagnosis, it is always one of exclusion.…”

“…In patients with TB-IRIS and TBM, CSF pleocytosis is typically mild or may even be absent 12. Compared with other bacterial causes of meningitis, TBM is also more likely if symptoms have been present for more than 5 days 9. Abnormalities on chest radiography and meningeal enhancement on CT scan provide additional but non-diagnostic support for TBM.…”

Anti-transferrin receptor-modified amphotericin B-loaded PLA–PEG nanoparticles cure Candidal meningitis and reduce drug toxicity

“…Immunosuppression is usually followed by immunodeficiency disease, serious infection, or organ transplantation. [1][2][3] However, it is difficult to achieve an effective concentration of antifungal drugs at the site of infection due to the blockade presented by the blood-brain barrier (BBB). 4,5 Amphotericin B (AMB) is the broadest spectrum systemic antifungal agent available, but is no longer the primary drug of choice for invasive fungal infection due to its inherent low solubility, poor efficacy, and nephrotoxicity.…”