Incidence and risk factors of immune reconstitution inflammatory syndrome in HIV-TB coinfected patients

De, Dibyendu; Nath Sarkar, Rathindra; Phaujdar, Sibaji; Bhattacharyya, Kuntal; Krishna Pal, Hare

doi:10.1016/S1413-8670(11)70250-1

Article information

Abstract

Tuberculosis is one of the leading causes of development of Immune reconstitution inflammatory syndrome (IRIS) in HIV patients receiving antiretroviral therapy (ART).

Objective

To determine the incidence of IRIS in HIV-TB coinfected patients, and to find out the possible risk factors associated with IRIS.

Materials and Methods

Study commenced with 96 patients adhered to standard antitubercular therapy (ATT) and ART without defaultering, and followed up for six months.

Result

The mean (± SD) CD4 count and CD4 percentage at baseline was 59.16 (± 24.63) per mm3 and 4.59% (± 1.73) respectively. Only 18.75% developed IRIS after 57.05 (± 14.12) days of initiation of ART. Extrapulmonary tuberculosis was the most significant factor associated with IRIS (83.33%) than those without IRIS (44.87%) (p=0.0032). Specifically, tubercular lymphadenitis (38.88%, p=0.0364) and disseminated tuberculosis (33.33%, p=0.0217) were significantly associated with IRIS. The other risk factors associated with appearance of IRIS were higher CD4 count (p=0.0212) at three months after initiation of ART and increment of CD4 count (p=0.0063) and CD4 percentage (p=0.0016) during this period. The major manifestations of IRIS were fever (40%), followed by lymphadenitis (38%). The mortality rate in IRIS was not higher than those without IRIS.

Conclusion

Patients with extrapulmonary tuberculosis, especially tubercular lymphadenitis, were more likely to develop IRIS and fever was associated in most of them. Higher increment of CD4 count may indicate development of IRIS in presence of new or worsening tuberculosis lesion.

Keywords:

HIV

Tuberculosis

Immune reconstitution inflammatory syndrome

CD4 lymphocyte count

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References

[1.]

M. John, M.A. French.

Exacerbation of the inflammatory response to Mycobacterium tuberculosis after antiretroviral therapy.

Med J Aust, 169 (1998), pp. 473-474

Medline

[2.]

Antiretroviral Therapy Guidelines for HIV-infected Adults and adolescents including post-exposure prophylaxis by NACO 2007.

[3.]

D.M. Murdoch, W.D. Venter, A. Van Rie, C. Feldman.

Immune reconstitution inflammatory syndrome (IRIS): review of common infectious manifestations and treatment options.

AIDS Res Ther, 4 (2007), pp. 9

http://dx.doi.org/10.1186/1742-6405-4-9 | Medline

[4.]

S.D. Lawn, L.G. Bekker, R.F. Miller.

Immune reconstitution disease associated with mycobacterial infections in HIV-infected individuals receiving antiretrovirals.

Lancet Infect Dis, 5 (2005), pp. 361-373

http://dx.doi.org/10.1016/S1473-3099(05)70140-7 | Medline

[5.]

S. Sungkanuparph, A. Vibhagool, P. Mootsikapun, P. Chetchotisakd, S. Tansuphaswaswadikul, C. Bowonwatanuwong.

Opportunistic infections after the initiation of highly active antiretroviral therapy in advanced AIDS patients in an area with a high prevalence of tuberculosis.

AIDS, 17 (2003), pp. 2129-2131

http://dx.doi.org/10.1097/01.aids.0000088184.01779.8e | Medline

[6.]

E.M. Shankar, R. Vignesh, K.G. Murugavel, et al.

Immune reconstitution inflammatory syndrome in association with HIV/AIDS and tuberculosis: views over hidden possibilities.

AIDS Res Ther, 4 (2007), pp. 29-42

http://dx.doi.org/10.1186/1742-6405-4-29 | Medline

[7.]

M. Narita, D. Ashkin, E.S. Hollender, A.E. Pitchenik.

Paradoxical worsening of tuberculosis following antiretroviral therapy in patients with AIDS.

Am J Respir Crit Care Med, 158 (1998), pp. 157-161

http://dx.doi.org/10.1164/ajrccm.158.1.9712001 | Medline

[8.]

B. Gazzard.

BHIVA Writing Committee. British HIV Association (BHIVA) guidelines for the treatment of HIV-infected adults with antiretroviral therapy (2005).

HIV Med, 6 (2005), pp. 1-61

http://dx.doi.org/10.1111/j.1468-1293.2005.0311b.x | Medline

[9.]

F.C. Serra, D. Hadad, R.L. Orofino, et al.

Immune reconstitution syndrome in patients treated for HIV and tuberculosis in Rio de Janeiro.

Braz J Infect Dis, 11 (2007), pp. 462-465

Medline

[10.]

S.A. Shelburne, F. Visnegarwala, J. Darcourt, et al.

Incidence and risk factors for immune reconstitution inflammatory syndrome during highly active antiretroviral therapy.

AIDS, 19 (2005), pp. 399-406

Medline

[11.]

H. Furrer, R. Malinverni.

Systemic inflammatory reaction after starting highly active antiretroviral therapy in AIDS patients treated for extrapulmonary tuberculosis.

Am J Med, 106 (1999), pp. 371-372

Medline

[12.]

G. Breton, X. Duval, C. Estellat, et al.

Determinants of immune reconstitution inflammatory syndrome in HIV type 1-infected patients with tuberculosis after initiation of antiretroviral therapy.

Clin Infect Dis, 39 (2004), pp. 1709-1712

http://dx.doi.org/10.1086/425742 | Medline

[13.]

W. Manosuthi, S. Kiertiburanakul, T. Phoorisri, S. Sungkanuparph.

Immune reconstitution inflammatory syndrome of tuberculosis among HIV-infected patients receiving antituberculous and antiretroviral therapy.

J Infect, 53 (2006), pp. 357-363

http://dx.doi.org/10.1016/j.jinf.2006.01.002 | Medline

[14.]

J.A. Crump, M.J. Tyrer, S.J. Lloyd-Owen, L.Y. Han, M.C. Lipman, M.A. Johnson.

Military tuberculosis with paradoxical expansion of intracranial tuberculomas complicating human immunodeficiency virus infection in a patient receiving highly active antiretroviral therapy.

Clin Infect Dis, 26 (1998), pp. 1008-1009

Medline

[15.]

K.A. Wendel, K.S. Alwood, R. Gachuhi, R.E. Chaisson, W.R. Bishai, T.R. Sterling.

Paradoxical worsening of tuberculosis in HIVinfected persons.

Chest, 120 (2001), pp. 193-197

Medline

[16.]

F. Jon, Tuberculosis.

pp. 401-418

[17.]

C. Michailidis, A.L. Pozniak, S. Mandalia, S. Basnayake, M.R. Nelson, B.G. Gazzard.