Tuberculosis-Associated Immune Reconstruction Inflammatory Syndrome (TB-IRIS) in HIV-Infected Patients: Report of Two Cases and the Literature Overview
We describe two HIV-infected patients with tuberculosis-associated immune reconstruction inflammatory syndrome (TB-IRIS): one with “paradoxical” IRIS and the other with “unmasking” IRIS. TB-IRIS in HIV-infected subjects is an exacerbation of the symptoms, signs, or radiological manifestations of a pathogenic antigen, related to recovery of the immune system after immunosuppression. We focused on the radiological characteristics of TB-IRIS and the briefly literature review on this syndrome. 1. Introduction Tuberculosis- (TB-) associated immune reconstruction inflammatory syndrome (TB-IRIS) is emerging as an important early complication of combination antiretroviral therapy (CART) in patients with HIV infection all over the world. In Europe, and United States studies the reported incidence of TB-IRIS was from 11% to 45% [1–4]. The frequency of TB-IRIS among Croatian patients in the study of Puljiz and colleagues in 2006 was 40.7% [5]. IRIS is a condition that results from rapid restoration of pathogen-specific immune responses to opportunistic infections, causing either the deterioration of a treated infection or the new presentation of a previously subclinical infection [6, 7]. There is no diagnostic test for IRIS, and a confirmation of the disease relies heavily upon case definitions incorporating clinical and laboratory data [7]. Case definitions for IRIS were published by French and collaborators in 2004 and by Shelburne and colleagues in 2006 [8, 9]. A case definition specific for TB-IRIS was also suggested by Colebunders et al. in 2006 [10]. However, clinical management and research on IRIS were hindered by the lack of consensus case definitions and definitions that are specific to particular opportunistic infections [7]. To address this issue, in resource-limited settings, an international meeting of researches working in this field was convened in Kampala, Uganda in November 2006, and the international network for the study of HIV-associated IRIS (INSHI) was formed [7]. INSHI published criteria for “paradoxical” TB-IRIS and “unmasking” TB-IRIS diagnosis in 2008 aimed for use in settings in which laboratory infrastructure is often limited [7]. The phenomenon of “paradoxical” reaction during the treatment of TB in which existing disease may worsen or new lesions appear has been recognized for many years, before the association with HIV coinfection [11]. Most reported cases have complicated the treatment of lymph node or cerebral disease, with enlargement of nodes seen in approximately 30% in one large series [12, 13]. In the past few years an
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