IRIS After PCP: The Inflammation Nobody Wants

Le résumé fourni par la source

Abstract Immune Reconstitution Inflammatory Syndrome (IRIS) is a condition where a person's immune system overreacts to a previous infection after starting treatment for an underlying condition like HIV/AIDS. This can cause symptoms of the infection to worsen, even though the treatment is working. In this case, a patient with HIV who had Pneumocystis pneumonia (PCP) initially improved after starting treatment, but subsequently worsened due to IRIS. A 57-year-old man with a recent HIV diagnosis, not on antiretroviral therapy (ART), and obstructive sleep apnea (OSA) presented to the hospital with shortness of breath (dyspnea). He was admitted and treated for multifocal pneumonia with empirical antibiotics. CT scan of the chest showed symmetric diffuse ground-glass opacification. His oxygen requirements escalated from high-flow nasal cannula to bilevel positive airway pressure (BiPAP), and eventually required intubation due to acute respiratory distress syndrome (ARDS). Bronchoscopy was performed, and BAL samples tested positive for Pneumocystis jiroveci pneumonia (PJP) by polymerase chain reaction. Treatment with Bactrim and prednisone was initiated according to PCP guidelines. Two days into treatment, the patient developed hyperkalemia which was medically managed without significant improvement. Bactrim was subsequently switched to Atovaquone, leading to a significant decrease in the potassium level. In addition, the patient was started on Biktarvy and azithromycin for Mycobacterium avium complex prophylaxis, with a CD4 count of 54 cells/µL. He was successfully extubated and eventually titrated off oxygen with significant symptomatic improvement and decreased infiltrates on repeat imaging. He was eventually transferred out of the ICU. One week post ICU transfer the patient's condition worsened, requiring high-flow oxygen and CXR showing increasing pulmonary infiltration. This was thought to be related to IRIS and steroids were increased with continuation of ART. Over time, symptoms improved, oxygen needs decreased, and the patient was discharged. IRIS doesn't have a telltale symptom that sets it apart from other conditions. Its hallmark is a worsening of an existing infection, even as treatment progresses. In this case, the patient with pneumonia experienced a decline in respiratory health after initial improvement. Although ART has revolutionized HIV/AIDS treatment, it can paradoxically lead to IRIS. To minimize this risk, it's vital to start ART early, before CD4 cell counts decline, and identify as well as treat any existing or prior infections before starting ART. Early recognition and management of IRIS are crucial to prevent serious complications and improve patient outcomes.

Ce résumé expose les affirmations des auteurs. BNTIC ne l’interprète pas comme une validation indépendante des résultats.