Complications
IRIS is a systemic inflammatory syndrome clinically indistinguishable from active Mycobacterium avium complex (MAC) infection; it has been described among patients with subclinical or established MAC disease and advanced immunosuppression who begin antiretroviral treatment (ART) and have a rapid increase in their CD4 count (≥100 cells/microliter).[251][256]
This syndrome can manifest as early as 7 days after starting ART and is more common with baseline CD4 counts below 100 cells/microliter. IRIS presents with fever, weight loss, pulmonary consolidation, infiltrates, effusions, or lymphadenitis. Nonsteroidal anti-inflammatory drugs can provide relief. Neither anti-mycobacterial treatment nor ART should be changed. In severe reactions, corticosteroids are recommended.[1]
IRIS has also been associated with cytomegalovirus retinitis, cryptococcal meningitis, tuberculosis, progressive multifocal leukoencephalopathy, and herpesvirus infections in patients with previously diagnosed AIDS-defining illnesses starting ART. Treatment depends on the underlying infectious agent and its clinical presentation.[257][258] In patients with advanced immunosuppression and nontuberculous opportunistic infections, IRIS has been associated with the presence of a fungal infection, lower CD4 T-cell counts and higher HIV RNA levels at baseline, and higher CD4 T-cell counts and lower HIV RNA levels on treatment.[259]
IRIS occurs in 30% of patients with cryptococcal meningitis and HIV infection who start or re-start ART.[260] These patients should continue both ART and antifungal therapy. Corticosteroids may be needed for severe symptomatic IRIS.
In tuberculosis, pneumothorax results from rupture into the pleural space of a peripheral cavity or of a subpleural caseous focus that has liquefied. The associated bronchopleural fistula (BPF) may seal off or persist. Large BPFs may lead to empyema formation.
Risk factors for pneumothorax in HIV-positive patients with Pneumocystis jirovecii pneumonia include a history of cigarette smoking, aerosolized pentamidine treatment, and presence of pneumatoceles on chest radiography.
Management is with chest tube (tube thoracostomy). Persistent BPFs may require surgical repair.
Pyrimethamine can suppress the bone marrow. Leucovorin is given to prevent this toxicity. Leucovorin dosing can be increased further to offset effects on bone marrow. If this is ineffective, dosing of pyrimethamine may have to be decreased.
The most common side effect of ganciclovir or valganciclovir therapy is bone marrow suppression, most commonly with leukopenia and thrombocytopenia.
Elevated ICP with cryptococcal meningitis probably occurs due to impaired reabsorption of cerebrospinal fluid (CSF) at the arachnoid villi. Patients with elevated ICP should have serial, daily lumbar punctures, with drainage of up to 30 mL of CSF to control pressure. If high pressure persists despite daily lumbar punctures, a temporary lumbar drain or ventriculoperitoneal shunt may be considered.
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