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Tubercolosi , HIV e migrazione: una reale emergenza ?. SESSIONE II -ˇ HIV e Tubercolosi nella persona immigrata. La gestione della persona immigrata con coinfezione parte II. Miriam Lichtner Dipartimento di Malattie Infettive e Sanità Pubblica Sapienza Università di Roma Polo Pontino

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la gestione della persona immigrata con coinfezione parte ii

Tubercolosi, HIV e migrazione: una reale emergenza?

SESSIONE II -ˇ HIV e Tubercolosi nella persona immigrata

La gestione della persona immigrata con coinfezioneparte II

Miriam Lichtner

Dipartimento di Malattie Infettive e Sanità Pubblica Sapienza Università di Roma Polo Pontino

Componente dell’ Italian National Focal Point – InfectiousDiseases and Migrant”

slide2

Sergej

  • Dopo 4 mesi di ART e 2 di anti-TB (11/04/07): febbre elevata con sospetto di IRIS, inizia deltacortene e streptomicina
  • CD4+ 98/mmc, HIV-RNA<50
  • Dimissione 26/4/07 controllo DH dopo 1 sett
quadri storici di iris
Quadri storici di IRIS
  • Reazioneparadossalenella TB dopoiniziotrattamento
  • Reazioneinfiammatorianeipz con lebbra in trattamento
  • Recupero del sist. immune dopotrapianto di midollo e chemioterapia
  • Rispostaatipicainfiammatoriaaimicobatteriatipicineipz in terapia con AZT (anni 80)
antiretroviral therapy improves qualitative and quantitative immune defects

Immune suppression/deficiency

Impaired pathogen-specific immunity

Quantitative immune defects

CD4 counts

Qualitative/functional immune defects

Response to recall antigens

HIV replication

Immune activation

OI

Immune Reconstitution

HAART

Qualitative/functional immune defects

Reversal of anergy

Lymphocyte proliferative capacity

Quantitative immune defects

Redistribution, death (HIV-, activation-induced), production (peripheral expansion and thymic)

Improved pathogen-specific immunity

Improved immune control

HIV replication

Immune activation

Antiretroviral Therapy Improves Qualitative and Quantitative Immune Defects

Migueles, Buenos Aires 2003

defining iris
Defining IRIS

Source: CID J 2006;(1 June) 42: 1639-46

defining iris1
Defining IRIS
  • Proposed criteria for the diagnosis of IRIS
  • HIV positive
  • Receiving HAART
    • Decrease in HIV-1 RNA level from baseline
    • Increase in CD4 cells from baseline(may lag HIV-1 RNA decrease)
  • Clinical symptoms consistent with inflammatory process
  • Clinical course NOT consistent with:
    • Expected course of previously diagnosed OI
    • Expected course of newly diagnosed OI
    • Drug toxicity
  • Source: Journal of Antimicrobial Chemotherapy (2006) 57, 167-170;
  • Samuel A. Shelburne, Martin Montes and Richard J.Hamill
defining iris major criteria
Defining IRIS: Major Criteria
  • Previous diagnosis of AIDS
  • Concurrent Antiretroviral Therapy; Increase in CD4 count and Decrease in plasma vireamia by > 1 log copies/ml
  • Atypical presentation of ‘opportunistic infection or tumor’ i.e.
    • localized disease or
    • exaggerated inflammation or
    • atypical inflammatory response or
    • worsening of pre existing disease.
    • Symptoms consistent with infectious/inflammatory condition
  • Symptoms not explained by normal course of previous or new OI or side effect of ART

Source: Battegay and Drechsler; Current Opinion in HIV and AIDS; 2006, 1; 56-61

defining iris minor criteria
Defining IRIS: Minor Criteria
  • Increase in CD4 cell count
  • Increase in measured specific immune response
  • Spontaneous resolution of symptoms without specific therapy

Source: Battegay and Drechsler; Current Opinion in HIV and AIDS; 2006, 1; 56-61

onset of iris
Onset of IRIS

Source: AIDS 2005, Vol 19 No4 ;399-406, Samuel A. Shelburne et al

risk factors
Risk factors
  • Risk factors at base line:
    • Lower CD4 count prior to start of ART
    • Higher HIV-1 RNA levels at base line
    • Initiating ART in close proximity to starting therapy for an OI
  • Response to therapy & the development of IRIS:
    • Rapid fall in HIV-1 RNA level during the first 3 months of therapy
  • Source: Journal of Antimicrobial Chemotherapy (2006) 57, 167-170;Samuel A. Shelburne, Martin Montes and Richard J.Hamill
risk factors for iris
Risk factors for IRIS

Microbial

antigens

Host

susceptibility

CD4< 50

Adapted from French et al, 2004

management
Management
  • Mild form (with ongoing ART)
    • Observation
  • Localized IRIS (with ongoing ART)
    • Local therapy such as minor surgical procedures for lymph node abscesses
  • Most of the situations (with ongoing ART)
    • Unmasking &/or Recognition of ongoing infections >> Antimicrobial therapy to reduce the antigen load of the triggering pathogen;
    • Reconstituting immune reaction to non-replicating antigens >> no antimicrobial therapy. Short term therapy with corticosteroids or non-steroidal anti inflammatory drugs to reduce the inflammation.
management1
Management
  • Temporary cessation of ART has to be considered if potentially life threatening forms of IRIS develop