Immune Reconstitution Inflammatory Syndrome in a Resource-Poor Setting

Abstract

The immune reconstitution inflammatory syndrome (IRIS) associated with highly active antiretroviral therapy (HAART) was studied in rural Ethiopian HIV-infected patients. Review of 1002 charts in an outpatient clinic was conducted. The median CD4 count was 89 cells/mm3. Ninety-eight patients were hospitalized after initiation of HAART, of whom 74 were hospitalized for manifestations of IRIS (ie, 7% of patients on HAART). Of the 74 patients hospitalized with IRIS, 27 patients had tuberculosis; 12 patients, cryptococcal meningitis; 7 patients, toxoplasmosis; 6 patients, pneumonia and/or effusion; and 5 patients, Pneumocystis jiroveci pneumonia (PCP). Ten adult patients were admitted with gastroenteritis, heretofore not recognized as a manifestation of IRIS. Eighty-one percent of IRIS patients were hospitalized within 3 months of beginning HAART and 99% by 6 months. Of those hospitalized with IRIS, 4 patients (5%) died while in the hospital (3 with cryptococcal meningitis). Thirty-seven or 50% of those hospitalized with IRIS were lost to medical follow up, thus the mortality rate is likely a gross underestimate of the severity of IRIS. In resource-poor settings where the primary goal is to initiate HAART, IRIS may go unrecognized and have fatal consequences.

Clinical characteristics, predictors of immune reconstitution inflammatory syndrome and long-term prognosis in patients with Kaposi sarcoma

“…Our very high prevalence could be biased; since our institution is a tertiary-care center receiving patients with more extended KS disease [31]. The median time to development of KS-IRIS was 10 weeks, similar to the previously reported 6–14 week lapse after cART initiation [17, 19, 26, 33, 34]. IRIS associated to other pathogens (i.e., cytomegalovirus, MTB, MAC, and hepatitis B) has been reported to occur earlier within 2–5 weeks after cART initiation [33–35].…”

“…IRIS has been reported to occur in 10‒30% of antiretroviral-naïve patients with a 5–30% mortality rate [5, 16]. In Africa, it has become a significant cause of morbidity and mortality in HIV-infected patients with access to cART [5, 17, 18]. IRIS has been described in association with different infectious processes [10, 19–21].…”

Cryptococcal meningitis: epidemiology and therapeutic options

“…Studies from South Africa and Ethiopia estimate an incidence of 7%–33% 171–173. Paradoxical IRIS also affects solid organ-transplant patients when antirejection medications are interrupted during CM therapy,141 and apparently healthy hosts may suffer from reactivation of immune defenses that were previously overwhelmed by high fungal burden.…”

The Immune Reconstitution Inflammatory Syndrome with Tuberculosis

“…A similar study done in the Dessie Referral Hospital determined that *3% of patients with TB-IRIS had severe-enough disease to be hospitalized. 18 Our current study in the same institution revealed that 7% or 143 patients of 1977 outpatients initiating ART developed TB-IRIS within 6 months of beginning ART. A low baseline CD4 count at the initiation ART and a history of WHO Clinical Stage 3 or 4 were identified as independent risk factors.…”