MYCOBACTERIUM RELATED IMMUNE RECONSTITUTION INFLAMMATORY SYNDROME (IRIS) A CASE SERIES
Wella Yurisa,Nia Kurniati,Dina Muktiarti
Department of Child Health Faculty of Medicine Universitas Indonesia Cipto Mangunkusumo National General Hospital Jakarta Indonesia
Background : Immune reconstitution inflammatory syndrome (IRIS) is a collection of inflammatory disorders associated with paradoxical worsening of preexisting infectious processes following the initiation of antiretroviral therapy (ART) in HIV-infected individuals. Preexisting infections in individuals with IRIS may have been previously diagnosed and treated or they may be subclinical and unmasked by the host's regained capacity to mount an inflammatory response.
Case Presentation Summary : Two cases of mycobacterial related IRIS were found in the last 2 years (2016-2018). IRIS was confirmed through significant decrease of viral load and increase of CD4 cells after ART initiation. The first case was an 11-year-old girl who initially got 1st line ART but proven immunological failure. Evaluation for opportunistic infection (OI) before initiating 2nd line ART found tuberculosis (TB). She got treatment for 6 months but developing TB again after switching to 2nd line ART for 1 week. The second case was an 8-month-old baby who had multiple BCG lymphadenitis after initiation of ARV for 1 month. The baby was vaccinated with BCG before he was diagnosed with HIV. Patient was treated with anti-tuberculosis drugs and has finished the treatment course already. Both was confirmed IRIS by decreasing viral load from 99.300 copies/ml to 139 copies/ml in the 1st case and 2.700.000 copies/ml to 106 copies/ml in the 2nd case. They also had an increasing CD4 counts from 33 cells/ul to 61 cells/ul and 317cells/ul to 836 cells/ul, respectively. Both patients continued the ART and responded well with anti-tuberculosis drugs.
Learning Points/Discussion : Optimization of screening for subclinical OI and treatment for underlying OI is prerequisite prior to ART initiation to reduce the risk for IRIS. The diagnosis was made by clinical deterioration with decreased of viral load after initiation of ART. Treatment of IRIS involves optimal treatment of causal pathogen, supportive measures and continuing ART.
Keywords: HIV infected children IRIS Mycobacterium infection
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