Immune reconstitution disease of the central nervous system

Abstract

Reports of central nervous system immune reconstitution disease are increasing and this trend is likely to continue as access to antiretroviral therapy improves in resource-limited settings in which many central nervous system infections are endemic. Considerable challenges remain in the prevention, diagnosis and management of these conditions.

Neurologic Complications of HIV-1 Infection and Its Treatment in the Era of Antiretroviral Therapy

“…PML-IRIS typically develops within 4 to 8 weeks after the initiation of ART but has been reported to occur as late as 2 years. 53 The mortality rate may be 42% or higher in PML-IRIS, 54 with a worse prognosis associated with HIV-infected patients diagnosed first with PML and subsequently developing PML-IRIS after initiation of ART. 55 Clinical response to steroids confirms the diagnosis of PML-IRIS, as steroids will have no effect on PML but will help control the inflammatory response and frequently produce some clinical improvement in PML-IRIS.…”

“…60 Cryptococcal infections may be associated with 10% to 30% of all CNS-IRIS, 53 most often clinically manifest as aseptic recurrence of prior meningitis and rarely as intracranial cryptococcoma.…”

Neurotuberculosis and HIV Infection

“…The degree of immunodeficiency in HIV patients with NTB could be assessed using the CD4+T cell count. Most studies on TBM disclose a CD4+T cell count between 32-200 /mm 3 [5,81,82].Other findings including a lower hematocrit, peripheral low neutrophils, lower plasma sodium level [76] and moderate to severe anemia Hb < 8 gm/dl [69] were not constantly present in all studies and could be mostly related to the HIV infection than to TB. Moreover hyponatremia in patients with HIV-TB co-infection could arise due to the following: a) cerebral salt wasting syndrome observed in 65% of patients with numerous cerebral lesions, including patients with TBM [83]; b) the syndrome of inappropriate release of antidiuretic hormone secretion; c) hypothalamus pituitary-adrenal axis suppresion.…”

“…However the basal meningeal enhancement and hydrocephalus rarely occur in advanced stages of AIDS with reduced inflammatory response [76]. On the other hand cerebral infarctions and focal mass lesions are frequently encountered in late stages of AIDS [80][81][82]. In addition to the previous aspects imaging studies also disclose cerebral atrophy due to HIV infection.…”

The immune reconstitution inflammatory syndrome related to HIV co-infections: a review

“…IRIS-related CNS complications of herpes simplex virus and varicella zoster virus are rare, but they may cause permanent neurological disability or death [1,28,29].…”