Immune Reconstitution Inflammatory Syndrome (IRIS) and HIV

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Immune reconstitution inflammatory syndrome (IRIS) is an exaggerated inflammatory reaction from a re-invigorated immune system presenting as the unmasking of previously sub-clinical opportunistic infections OR clinical deterioration of pre-existing opportunistic infections OR development of the autoimmune disease.

  • Onset: usually within 2-12 weeks after starting ART
  • Frequency: 10% among all patients on ART, up to 25% when ART initiated with CD4 < 50 cells/μL
    Risk factors:
  • Initiating ART close to a diagnosis of an opportunistic infection
  • Initiating ART when CD4 is less than 50 cells/μL
  • Rapid initial fall in HIV-1 RNA level in response to ART in patients with low CD4 counts
  • Commonly seen with TB, cryptococcal disease, Kaposi’s sarcoma, and Mycobacterium avium complex infection
  • Patients initiated on DTG and with low CD4 counts have a higher risk of having IRIS

Management of IRIS

  • Have a high index of suspicion with early complications
  • ART should be continued
  • If ART continuation is impossible, temporarily interrupt the ART and restart the same regimen after OI or IRIS is addressed
  • Diagnose and treat OI or inflammatory condition
  • Corticosteroid treatment in moderate to severe cases: Prednisolone 0.5-1.0mg/kg/day for 5-10 days.