JAC Advance Access originally published online on September 14, 2006
Journal of Antimicrobial Chemotherapy 2006 58(5):1094; doi:10.1093/jac/dkl362
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Correspondence |
Comment on: Immune reconstitution inflammatory syndrome: more answers, more questions
Infectious Diseases Service, Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul Porto Alegre, Brazil
*Corresponding author. Tel/Fax: +55-51-33621850; E-mail: apzavascki{at}terra.com.br
Keywords: AIDS , HAART , immune reconstitution syndrome , immune reconstitution inflammatory syndrome , immune reconstitution disease , salvage therapy
Sir,
We read with interest the article by Shelburne et al.1 that reviewed the current concepts and challenges in the immune reconstitution inflammatory syndrome (IRIS). As stated by the authors, a major obstacle to quality research on IRIS has been the difficulty in establishing a definition.1 Since the recognition of IRIS, most of the investigations on this issue have been focused on patients who are starting highly active antiretroviral therapy (HAART), excluding HAART-experienced patients, particularly multi-failed ones. Although HAART-naive status has been found to be a risk factor for IRIS,2 many proposed definitions of this syndrome have been limited to this population.3–5
We have recently observed in our institution, two cases of heavily pre-treated patients who developed IRIS following salvage therapy, reinforcing that such a syndrome is not limited to naive patients who start HAART. It is known that, although less frequently and less robust, immune reconstitution may occur in patients with advanced disease, even in those who have experienced multiple HAART failures.6 Our observations suggest that this immune recovery can be strong enough to trigger IRIS, and this diagnosis should be considered even in heavily HAART-experienced patients if there is a favourable response to salvage therapy. We believe that case-definitions of this syndrome should not exclude these patients. Additional studies on clinical, pathological and epidemiological features of IRIS in HAART-experienced patients are required.
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References
1
Shelburne SA, Montes M, Hamill RJ. (2006) Immune reconstitution inflammatory syndrome: more answers, more questions. J Antimicrob Chemother 57:167–70.
2 Shelburne SA, Visnegarwala F, Darcourt J, et al. (2005) Incidence and risk factors for immune reconstitution inflammatory syndrome during highly active antiretroviral therapy. AIDS 19:399–406.[Web of Science][Medline]
3 Robertson J, Méier M, Wall J, et al. (2006) Immune reconstitution syndrome in HIV: validating a case definition and identifying clinical predictors in persons initiating antiretroviral therapy. Clin Infect Dis 42:1639–46.[CrossRef][Web of Science][Medline]
4 Hirsch HH, Kaufmann G, Sendi P, et al. (2004) Immune reconstitution in HIV-infected patients. Clin Infect Dis 38:1159–66.[CrossRef][Web of Science][Medline]
5 Ratnam I, Chiu C, Kandala NB, et al. (2006) Incidence and risk factors for immune reconstitution inflammatory syndrome in an ethnically diverse HIV type 1-infected cohort. Clin Infect Dis 42:418–27.[CrossRef][Web of Science][Medline]
6 Mezzaroma I, Carlesimo M, Pinter E, et al. (1999) Long-term evaluation of T-cell subsets and T-cell function after HAART in advanced stage HIV-1 disease. AIDS 13:1187–93.[CrossRef][Web of Science][Medline]
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