Somnuek Sungkanuparph|Ubonvan Jongwutiwes|Sasisopin Kiertiburanakul
Timing of Cryptococcal Immune Reconstitution Inflammatory Syndrome After Antiretroviral Therapy in Patients With AIDS and Cryptococcal Meningitis
Siriraj Hospital|Ramathibodi Hospital|Mahidol University|Siriraj Hospital|Ramathibodi Hospital|Mahidol University|Siriraj Hospital|Ramathibodi Hospital|Mahidol University
editor cryptococcosis common lethal fungal infection patients aids introduction combined antiretroviral therapy art markedly decreased overall mortality advanced hivinfected patients1 initiation art patients experience immune reconstitution inflammatory syndrome iris wellrecognized complication art patients extremely low initial cd4 cell counts2 syndrome described multiple opportunistic pathogens commonly mycobacterium avium complex mycobacterium tuberculosis cryptococcus neoformans cytomegalovirus hepatitis virus38 various studies reported 8 50 patients cryptococcal infection responded art developed cryptococcal iris despite use fluconazole therapy810 lortholarya et al9 demonstrated independent risk factors occurrence cryptococcal iris hiv infection revealed cryptococcosis low cd4 cell count fungemia baseline initiation treatment within 2 months cryptococcosis noncryptococcal iris patients present first 8 weeks start art31112 little information regarding timing cryptococcal iris however previous small studies described cryptococcal iris occur short 2 weeks 22 months initiation art813 clarify timing cryptococcal iris art patients aids retrospective cohort study conducted among hivinfected patients initiated art first episode cultureproven cryptococcal meningitis cryptococcal iris defined culturenegative cryptococcosis immunologic response art according criteria previously described2 kaplanmeier survival analysis used determine timing cryptococcal iris occurrence art cox proportional hazard modeling used determine predicting factor cryptococcal iris 52 patients mean sd age 344 69 years 60 male median range cd4 count 26 193 cellsmm3 patients presented first episode cultureproven cryptococcal meningitis patients received secondary prophylaxis treatment cryptococcal meningitis median range time art initiation diagnosis cryptococcal meningitis 26 08106 months patients 96 received nonnucleoside reverse transcriptase inhibitorbased regimens 6 12 months art median range cd4 counts 121 59203 cellsmm3 237 87302 cellsmm3 respectively intenttotreat analysis 88 78 patients achieved undetectable hiv rna 50 copiesml corresponding periods median range followup period 157 79540 months 10 patients 19 developed cryptococcal iris timing 30 273 months initiation art patients presented aseptic meningitis high opening pressure positive cryptococcal antigen cerebrospinal fluid csf culturenegative art continued patients patient cryptococcal iris died kaplanmeier analysis median survival free cryptococcal iris duration 54 months 75 survival free cryptococcal iris duration 215 months fig 1 among patients cryptococcal iris median time develop syndrome 99 95 confidence interval 39 179 months cumulative 25 75 occurrences cryptococcal iris 86 210 months respectively cox proportional hazard modeling including various factors baseline cd4 cell count baseline hiv rna level fungemia baseline cryptococcal antigen titer type art regimen initiation art within 2 months cryptococcosis cd4 cell count hiv rna level change 6 12 months art factors predict occurrence timing cryptococcal irisfigure 1 kaplanmeier survival curve demonstrating timing cryptococcal iris initiation artthe results present study demonstrated timing cryptococcal iris seems quite variable interestingly syndrome uncommon within first 3 months art may occur late 27 months initiation art iris presenting first 3 months art reflects immune response active infection opportunistic pathogens whereas late iris may result immune response antigens nonviable pathogens2 may explain secondary prophylaxis cryptococcosis cannot prevent cryptococcal iris unfortunately predicting factor occurrence timing cryptococcal iris present study risk factors occurrence cryptococcal iris reported literature include low cd4 cell count fungemia baseline initiation treatment within 2 months cryptococcosis29 factors significant predictors occurrence timing cryptococcal iris cox proportional hazard models however recent study reported model predict iris may accurate least applicable asian populations14 accurate predicting factors finding demonstrates difficulty diagnosing cryptococcal iris particularly occurs late art physicians aware syndrome note patient developed cryptococcal iris 27 months art first 3 years art immune reconstitution cryptococcosis recognized patients presenting culturenegative cryptococcosis occurrence syndrome indicate art failure acknowledgment study presented 14th conference retroviruses opportunistic infections los angeles ca february 2528 2007 abstract p 842 somnuek sungkanuparph md ubonvan jongwutiwes md sasisopin kiertiburanakul md department medicine faculty medicine ramathibodi hospital mahidol university bangkok bangkok thailand department medicine faculty medicine siriraj hospital mahidol university bangkok bangkok thailand