Timing of Cryptococcal Immune Reconstitution Inflammatory Syndrome After Antiretroviral Therapy in Patients With AIDS and Cryptococcal Meningitis

Abstract

Cryptococcosis is the most common lethal fungal infection in patients with AIDS. The introduction of combined antiretroviral therapy (ART) has markedly decreased the overall mortality for these advanced HIV-infected patients. After initiation of ART some patients experience immune reconstitution inflammatory syndrome (IRIS) a well-recognized complication of ART in patients with extremely low initial CD4 cell counts. This syndrome has been described in multiple opportunistic pathogens commonly with Mycobacterium avium complex Mycobacterium tuberculosis Cryptococcus neoformans cytomegalovirus and hepatitis virus. Various studies reported that 8% to 50% of patients with cryptococcal infection who responded to ART developed cryptococcal IRIS despite the use of fluconazole therapy. Lortholarya et al have demonstrated that independent risk factors for the occurrence of cryptococcal IRIS are HIV infection that was revealed by cryptococcosis low CD4 cell count fungemia at baseline and initiationof treatment within 2 months of cryptococcosis. In noncryptococcal IRIS most patients present in the first 8 weeks after the start of ART. There is little information regarding timing of cryptococcal IRIS however. Previous small studies have described that cryptococcal IRIS can occur from as short as < 2 weeks to 22 months after initiation of ART. (excerpt)