Critical Care Medicine-Infections and Immunologic Disease>>>>>Infections in the Immunocompromised Host
Question 2#

A 29-year-old male is admitted from the emergency department with fevers. He complained of night sweats and painful cervical lymphadenitis for the last 7 days. He was diagnosed with HIV/AIDS 1 month ago when he was admitted with an episode of communityacquired pneumonia. His CD4 count was 80 cells/µL and HIV RNA viral load was 1 million copies/mL at the time of diagnosis. He was started on anti-retroviral therapy (ART) with tenofovir-emtricitabine and raltegravir. On examination, his blood pressure is 90/45 mm Hg and pulse rate is 106 beats per minute. Blood cultures are in process. He is appropriately fluid resuscitated and started on vancomycin and piperacillin-tazobactam to cover potentially hospital-acquired pathogens. Immune reconstitution inflammatory syndrome (IRIS) secondary to disseminated mycobacterium avium complex (MAC) infection is suspected.

What is the NEXT BEST step regarding his ART during this admission?

A. Hold ART and resume in 1 week
B. Hold ART and resume in 2 weeks
C. Continue ART
D. Optimize ART by increasing the dose of current medications
E. Optimize ART by changing the ART regimen to include two new medications

Correct Answer is C


Correct Answer: C

This patient’s clinical presentation is suggestive of IRIS, an inflammatory disorder manifesting with the emergence or worsening of a preexisting, underlying infection. IRIS usually develops within weeks to months after the initiation of ART during immune recovery. Symptoms and signs relate to the exposed infection.

The diagnosis of IRIS requires the presence of AIDS with a pretreatment CD4 count less than 100 cells/µL, a positive virologic and immunological response to ART, and a temporal association between ART initiation and the onset of clinical features of illness. Common opportunistic infections associated with IRIS are mycobacterial and cryptococcal infections although any infection can present with IRIS.

In this case, the clinical presentation is consistent with MAC infection. Symptoms of MAC are generally nonspecific but often include fevers and diffusely painful lymphadenitis. Laboratory abnormalities include anemia, elevated alkaline phosphatase, and elevated lactate dehydrogenase. The diagnosis is typically confirmed by the isolation of MAC on cultures, although the microorganism burden may be low in IRIS. MAC usually grows on culture within 7 to 10 days.

Management of ART is crucial in IRIS associated with AIDS. Mild manifestations of IRIS usually resolve spontaneously in few days to weeks. Patients with severe symptoms may need adjunctive corticosteroids. Patients on ART who develop IRIS should continue ART alongside appropriate treatment of the exposed opportunistic infection. If the patient presents with MAC at the time of AIDS diagnosis, however, ART should be held until antimicrobial therapy for MAC has been initiated for 2 weeks.


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