Immune reconstitution inflammatory syndrome (IRIS) associated with Cryptococcus neoformans infection in AIDS patients

Abstract

Eighty-one AIDS individuals admitted at the teaching hospital with cryptococcal meningitis were evaluated and from these, 40 were prospectively followed. Of 40 patients with cryptococcosis, nine (22.5%) presented clinical and laboratory features of IRIS. Six (66.6%) were male, with a mean age of 37.2. Five (55.5%) presented cryptococcosis as first AIDS defining condition. In seven (77.9%) IRIS was characterised as a relapse of meningeal symptoms after 10 weeks, mean time of 72 days, of starting HAART whereas, two asymptomatic patients developed the syndrome as an unmasked cryptococcosis after 10 and 12 weeks on HAART. Lymphadenitis as isolated finding associated with IRIS was evidenced in three cases. All patients presented low CD4(+) and high RNA viral load baseline values. Cultures of cerebrospinal fluid and lymph-node fragments tissues of these cases were negative. Six of nine individuals developed high intracranial pressure requiring a daily relief lumbar puncture. No deaths occurred during the evolution of these patients. The incidence and clinical evolutive profile observed in this case series are in accordance with other reports elsewhere.

Paradoxical immune reconstitution inflammatory syndrome associated with cryptococcal meningitis in China: a 5-year retrospective cohort study

“…In addition, the 11% mortality in this case series is generally lower than that in Africa, but high than that in Brazil (0%) [9] and Thailand (0%) [8]. It is unclear which factors lead to such a dramatic difference, but several studies suggested that mortality due to CM-IRIS is low if recognised early and managed appropriately [9][10][11]. Thus, the variation in reported mortality may partly reflect difference in capacity for early diagnosis and quality of case management.…”

“…Although this proportion is comparable to previous retrospective studies conducted in the United States (21%) [7] and Thailand (19%) [8], in view of the chance of misdiagnosis and shorter follow-up, we speculate this figure may be an underestimation for its real burden in China. In addition, the 11% mortality in this case series is generally lower than that in Africa, but high than that in Brazil (0%) [9] and Thailand (0%) [8]. It is unclear which factors lead to such a dramatic difference, but several studies suggested that mortality due to CM-IRIS is low if recognised early and managed appropriately [9][10][11].…”

Shunting in cryptococcal meningitis

“…In a recent prospective series, 22.5% of treated patients with cryptococcal meningitis developed IRIS within 12 weeks of starting HAART. 7 Cerebral edema can be severe and associated with intracranial hypertension. 41 Current infectious disease guidelines advocate for the use of corticosteroids such as prednisone to control the inflammatory response.…”

Impact of Surfactant Protein D, Interleukin-5, and Eosinophilia on Cryptococcosis

“…For example, Th1-skewed immune responses are generally considered host protective, while Th2-biased immune responses, characterized by high levels of interleukin-4 (IL-4), IL-5, and eosinophil expression, are nonprotective in the context of C. neoformans infection (2)(3)(4)(5)(6)(7)(8). Furthermore, an overexuberant inflammatory response can lead to complications such as cryptococcal immune reconstitution inflammatory syndrome (IRIS) (9)(10)(11). Thus, fine-tuned regulation of the inflammatory response is necessary to ensure a favorable outcome for the host against C. neoformans infection.…”