ID Board Review/Human Immunodeficiency Virus (HIV) Infection/Complications of HIV/Opportunistic Infections (OIs)/Immune reconstitution inflammatory syndrome (IRIS)

Definition Dramatic inflammatory response to OI as immune response improves with initiation of ART Immune system reconstitution “unmasks” active infections: Most commonly Mycobacterium avium, TB, or fungal infections CMV retinitis, and crytpococcal meningitis can occur too Typically occurs weeks-months after starting ART, w HIV VL falling sharply and CD4 rising Clinical Diagnosis High level of IRIS suspicion based on timing Must rule out other causes and other infections Management Continue treating OIs Continue ART if possible May need to hold for a few days if Sx get severe Treat symptomatically May resort to steroids if IRIS is extremely severe Prevention In Pts w TB + HIV, start on TB treatment for at least 2 weeks Then start ART In Pts w cryptococcal meningitis + HIV, Tx the Crypto until intracranial pressures normalize DO NOT START TX SIMULTANEOUSLY