Perforación intestinal por citomegalovirus durante un Síndrome de Reconstitución Inmune / Intestinal Perforation for Cytomegalovirus in Immune Reconstitution Syndrome

RESUMEN El síndrome de reconstitución inmune se produce debido a un aumento de la inmunocompetencia en pacientes previamente inmunocomprometidos. La situación es frecuente tras iniciar un tratamiento antirretroviral de alta eficacia, en pacientes con infección por el virus de inmunodeficiencia humana. En determinados casos, puede conllevar un empeoramiento paradójico de una infección previa. El citomegalovirus, es un germen oportunista que, en el seno de un síndrome de reconstitución inmune, puede dar lugar a perforación intestinal multifocal y peritonitis secundaria de difícil tratamiento. Es más frecuente en pacientes con recuento de linfocitos cooperadores inferior a 50 células/mm3 al iniciar el tratamiento antirretroviral. El objetivo es comunicar dicha situación a través, de un caso clínico para facilitar su sospecha lo más pronto posible, y realizar un tratamiento adecuado. Presentamos el caso de un paciente con virus de inmunideficiencia humana de reciente diagnóstico, en tratamiento con terapia antirretroviral de alta eficacia, que acude a urgencias con abdomen agudo secundario a perforación por citomegalovirus. La infección conlleva importante morbimortalidad, siendo imprescindible un diagnóstico temprano e iniciar precozmente el tratamiento antiviral intravenoso, asociado generalmente a tratamiento quirúrgico(AU)

ABSTRACT Immune reconstitution syndrome occurs due to increased immunocompetence in previously immunocompetent patients. The condition is frequent in patients with human immunodeficiency virus infection who have started a highly active antiretroviral therapy. In certain cases, the syndrome can lead to a paradoxical worsening of a previous infection. Cytomegalovirus is an opportunistic germ that, during an immune reconstitution syndrome, can lead to multifocal intestinal perforation and secondary peritonitis, in cases that are difficult to treat. The syndrome is more frequent in patients with CD4 lymphocyte count below 50/mm3 at the time of starting antiretroviral treatment. The objective is to communicate this situation through a clinical case presentation in order to facilitate suspicion as soon as possible, and to carry out appropriate treatment. We present the case of a patient with a recently diagnosed human immunodeficiency virus, under treatment with highly active antiretroviral therapy, who attended the emergency department with an acute abdomen secondary to perforation due to cytomegalovirus. Infection carries significant morbidity and mortality, and early diagnosis is essential and intravenous antiviral treatment should be started early, generally associated with surgical treatment(AU)

Síndrome de reconstitución inmune / Immune reconstitution syndrome

ResumenEl síndrome inflamatorio de reconstitución inmune se presenta en pacientes con infección por VIH o infección avanzada por el virus, días, semanas o meses después del inicio de la terapia antirretroviral. Se caracteriza por una restauración gradual de la inmunidad patógeno-específica donde el sistema inmune es capaz de reconocer atógenos presentes pero clínicamente ocultos. Característicamente se presenta después de iniciar la TARV cuando el sistema inmunitario comienza a recuperarse. Puede ser leve o potencialmente mortal.

AbstractThe immune reconstitution inflammatory syndrome occurs in patients with advanced HIV infection or HIV infection, days, weeks or months after initiation of antiretroviral therapy. It is characterized by a gradual restoration of pathogen specific immunity where the immune system is able to recognize pathogens presents but clinically occult.Characteristically it occurs after starting antiretroviral therapy when the immune system starts to recover. It can be mild or life threatening.

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

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 percent (± 1.73) respectively. Only 18.75 percent developed IRIS after 57.05 (± 14.12) days of initiation of ART. Extrapulmonary tuberculosis was the most significant factor associated with IRIS (83.33 percent) than those without IRIS (44.87 percent) (p = 0.0032). Specifically, tubercular lymphadenitis (38.88 percent, p = 0.0364) and disseminated tuberculosis (33.33 percent, 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 percent), followed by lymphadenitis (38 percent). 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.

A study of TB-associated immune reconstitution inflammatory syndrome using the consensus case-definition.

Background & objectives: A considerable proportion of patients with HIV associated tuberculosis (TB) started on highly active antiretroviral therapy (HAART) develop immune reconstitution inflammatory syndrome (IRIS), which is difficult to diagnose in a resource-limited setting. In view of the recently proposed consensus case-definitions for TB-IRIS for use in resource-limited settings we undertook this study to describe the incidence and risk factors of TB associated IRIS in a tertiary care hospital and research centre in north India. Methods: Retrospective analysis of antiretroviral treatment (ART) naïve adults started on highly active ART (HAART) from June 2006 to September 2008 was done. Results: Of the 627 patients studied, 237 (38%) had TB at the initiation of HAART. In total, 18 (7.5%) of 237 patients with TB at baseline had paradoxical TB-associated IRIS, and 12 (3%) of 390 patients without TB at baseline developed ART-associated TB. Most IRIS events occurred during the initial 30 days of HAART. Two patients developed TB-associated IRIS after 90 days of HAART. Using univariate analysis, low CD4+ cell count at baseline [64 (28-89) vs. 95 (52-150); P=0.009] and early initiation of HAART [33 (24-41) vs. 48 (35-61) days; P<0.001] were significantly associated with paradoxical TB-associated IRIS. No identifiable risk factors were associated with the development of ART-associated TB. Interpretation & conclusions: A considerable proportion of patients on HAART develop TB-associated IRIS. The consensus case-definition is a useful tool in resource-limited settings for the diagnosis of TB-associated IRIS.