gms | German Medical Science

10. Kongress für Infektionskrankheiten und Tropenmedizin (KIT 2010)

Deutsche Gesellschaft für Infektiologie,
Deutsche AIDS-Gesellschaft,
Deutsche Gesellschaft für Tropenmedizin und Internationale Gesundheit,
Paul-Ehrlich-Gesellschaft für Chemotherapie

23.06. - 26.06.2010, Köln

Immune Reconstitution Inflammatory Syndrome (IRIS) due to nontuberculous mycobacterial infection with disseminated cerebral involvement

Cerebrales immunrekonstitutielles inflammatorisches Syndrom (IRIS) durch nicht tuberkulöse Mykobakterien

Meeting Abstract

  • D. Ernst - Medizinische Hochschule Hannover, Klinik für Immunologie und Rheumatologie, Hannover, Germany
  • E. Bültmann - Medizinische Hochschule Hannover, Institut für Diagnostische und Interventionelle Neuroradiologie, Hannover, Germany
  • Y.-H. The - Medizinische Hochschule Hannover, Klinik für Immunologie und Rheumatologie, Hannover, Germany
  • D. Meyer-Olson - Medizinische Hochschule Hannover, Klinik für Immunologie und Rheumatologie, Hannover, Germany
  • N. Baerlecken - Medizinische Hochschule Hannover, Klinik für Immunologie und Rheumatologie, Hannover, Germany
  • R.E. Schmidt - Medizinische Hochschule Hannover, Klinik für Immunologie und Rheumatologie, Hannover, Germany
  • M. Stoll - Medizinische Hochschule Hannover, Klinik für Immunologie und Rheumatologie, Hannover, Germany

10. Kongress für Infektionskrankheiten und Tropenmedizin (KIT 2010). Köln, 23.-26.06.2010. Düsseldorf: German Medical Science GMS Publishing House; 2010. DocP130

DOI: 10.3205/10kit184, URN: urn:nbn:de:0183-10kit1847

Veröffentlicht: 2. Juni 2010

© 2010 Ernst et al.
Dieser Artikel ist ein Open Access-Artikel und steht unter den Creative Commons Lizenzbedingungen (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.de). Er darf vervielfältigt, verbreitet und öffentlich zugänglich gemacht werden, vorausgesetzt dass Autor und Quelle genannt werden.


Gliederung

Text

Background: After commencing antiretroviral combination therapy (c-ART), paradoxical and clinically atypical manifestations of opportunistic infections may arise. Such IRIS-events are assumed to be driven by an augmentation of a disbalanced inflammation. Mycobacteria frequently cause IRIS in HIV+ patients with advanced immunodeficiency. Nontuberculous mycobacterial IRIS often manifests with focal lymphadenopathy or abdominal granuloma-like conglomerate-tumours [1].

Case report: A 26 year old patient presented with newly diagnosed HIV-infection, progressive weight loss, with a CD4 count of 4/µl and a viral load of 500,000 copies/ml. 4 months after start of C-ART with FTC, TDF, LPV, and RTV he developed fever, diarrhoea, and abdominal lymphadenopathy. Microbiological screening revealed multiple acid-fast bacilli in the stool, but not in sterile compartements. Corticosteroid treatment for a suspected IRIS and antimycobacterial triple therapy with rifabutin (RBT), azithromycine (AZI) and ethambutol (EMB) was initiated, resulting in a good partial remission of the abdominal symptoms. Seven months later c-MRT scans identified disseminated parenchymal lesions suggestive for fungal infection, but CSF analysis and serology were unremarkable. Antimycobacterial treatment was stopped and therapy with corticosteroids, voriconazole and aciclovir was started along with carbamazapine as seizure prophylaxis. The patient's condition improved rapidly, but after five weeks he re-presented with seizures and progression of intracerebral lesions. Repeated CSF analysis and an EEG were unremarkable.Bone marrow and lymph node biopsy demonstrated active granulomatous disease. Antimycobacterial therapy was restarted and resulted in regression of cerebral lesions within 4 weeks. Meanwhile c-MRTs and abdominal imaging demonstrate complete remission under continuous antimycobacterial therapy with CLA and EMB.

(Figure 1 [Fig. 1])

Conclusion: Intracerebral involvement of nontuberculous mycobacterial disease is uncommon. IRIS may present after the initiation of c-ART with unusual, ambigious symptoms. Differential diagnosis is sometimes hindered by the discrepancy of progressive and overwhelming inflammation in the absence of an identifiable underlying infection. Empirical treatment with antiobiotics, administration of immunosuppression in combination with a close clinical monitoring is crucial.


References

1.
Stoll M, Schmidt RE. Autoimmunity Reviews 3. 2004:243-9.