Immune reconstitution inflammatory syndrome in the CNS of HIV-infected patients.
OBJECTIVE
To describe challenges in diagnosis and management of patients with clinical syndromes of immune reconstitution inflammatory syndrome (IRIS) involving the CNS.


METHODS
The authors describe three patients with clinically distinct neurologic manifestations of IRIS with HIV infection who presented as diagnostic and therapeutic challenges.


RESULTS
One patient with cryptococcal meningitis developed acute cerebellitis with mass effect and brainstem compression. Corticosteroid therapy was associated with complete resolution of the cerebellar lesion but the patient developed VZV encephalitis. Another patient with progressive multifocal leukoencephalopathy developed subacute progression of focal neurologic deficits associated with contrast enhancing lesions on brain MRI. This patient had spontaneous resolution of the lesion but was left with residual deficits. One patient developed a progressive dementing syndrome and deterioration over several months resulting in coma during combination antiretroviral therapy. A brain biopsy in this latter patient showed massive infiltration of T lymphocytes predominantly of the CD8 subtype. This patient had a significant improvement with corticosteroids and change in antiretroviral regimen although she was left with residual cognitive impairment.


CONCLUSIONS
Immune reconstitution inflammatory syndrome should be suspected in patients who show clinical or radiologic deterioration following initiation of antiretroviral therapy accompanied with improvement in CD4 cell count and viral load. Some patients may respond to a brief course of treatment with corticosteroids.
Venkataramana
A
A
Department of Neurology, Johns Hopkins University, Baltimore, MD 21287, USA.
Pardo
C A
CA
McArthur
J C
JC
Kerr
D A
DA
Irani
D N
DN
Griffin
J W
JW
Burger
P
P
Reich
D S
DS
Calabresi
P A
PA
Nath
A
A
D017088:AIDS-Related Opportunistic Infections; D000305:Adrenal Cortex Hormones / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active; D020274:Autoimmune Diseases of the Nervous System / Q000188:drug therapy* / Q000209:etiology* / Q000821:virology; D018791:CD4 Lymphocyte Count; D002493:Central Nervous System Diseases / Q000209:etiology / Q000821:virology; D015658:HIV Infections / Q000150:complications* / Q000188:drug therapy; D006801:Humans; D019562:Viral Load
D000305:Adrenal Cortex Hormones