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