MANIFESTATIONS OF IRIS
The list of conditions that can be affected by the reconstitution of immune function is extensive.2-4 Tuberculosis and infection with cytomegalovirus, M avium, or Cryptococcus neoformans are some of the most common conditions that are complicated by the initiation of antiretroviral medications. Cryptococcal meningitis is also a fairly common exacerbation and can be devastating. A number of disease processes have cutaneous components (such as herpes simplex or zoster, molluscum contagiosum, and genital warts [human papillomavirus]). Autoimmune diseases (thyroiditis, systemic lupus, and autoimmune alopecia) manifest with worsening symptoms. A number of inflammatory diseases (sarcoidosis and folliculitis) may become symptomatic. Lastly, neoplasias have been associated with IRIS and include exacerbations of lung cancer, lymphoma, and Kaposi sarcoma.
Management options for patients with IRIS are not wellestablished.5 Even though IRIS is self-limiting, treatment is utilized in the hope of assuaging the morbidity. Treatment strategies include corticosteroids, discontinuation of antiretrovirals, and other modalities. The approach should be tailored to the patient and the opportunistic infection or situation encountered.3
The appearance of IRIS may play an even greater role as efforts continue to make antiretrovirals available to underserved populations and in areas of the world where the burden of HIV is greatest and treatment is currently limited.3 The association of antiretrovirals and the onset of latent leprosy9 may add a complicating factor in areas where leprosy is endemic, such as India.10
A paradoxical worsening of symptoms has also been noted with other disease processes that are similar to HIV infection. Thus, although most of the information we have focuses on HIV, the implications for IRIS may be broader.11
WHAT PAs NEED TO KNOW
• IRIS is a host response to the presence of pathogens that occurs as the immune system recovers.
• Patients with immune-compromising disease are at risk for the emergence of acute symptoms that may be explained by IRIS.
• IRIS is a diagnosis of exclusion that requires a thorough work-up to characterize needed therapeutic interventions.
• If IRIS is suspected, communication with and referral to specialty care may be needed on an emergent basis. A history of new medications is especially important.
• This phenomenon may not be strictly limited to HIV-infected patients. IRIS may be a pathogenesis that also occurs with other diseases. JAAPA
The authors work at the College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City. Daniel O'Donoghue is a professor in the Department of Family and Preventive Medicine. Tara Gleaves works in the Department of Internal Medicine, Section of Infectious Diseases. Michelle Salvaggio is Assistant Professor, Department of Internal Medicine, Section of Infectious Diseases. All have indicated no relationships to disclose relating to the content of this article.
Sarah Zarbock, PA-C, department editor
DRUGS MENTIONED
Abacavir (Ziagen)
Clarithromycin (Biaxin, generics)
Darunavir (Prezista)
Efavirenz (Sustiva)
Ethambutol (Myambutol, generics)
Lamivudine (Epivir, Epivir-HBV)
Ritonavir (Norvir)
Tenofovir (Viread)
Zidovudine (Retrovir, generics)
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