Síndrome de restauração imune associada à histoplasmose

Abstract

Abstract:A 27-year-old HIV-positive male patient with disseminated cutaneous histoplasmosis was treated with both HAART and amphotericin B (total accumulated dose of 0.5g). Amphotericin B was later replaced with itraconazole (200mg/day). Two months after therapy had been started and the cutaneous lesions had healed, the patient interrupted both treatments voluntarily and his health deteriorated. HAART was then re-introduced and CD4+ cell count increased sharply at the same time as lymph node histoplasmosis was diagnosed. This paradoxical response ? the relapse of histoplasmosis and concomitant increase in CD4+ cell count and undetectable viral load after resumption of HAART ? suggests that this was a case of immune reconstitution inflammatory syndrome (IRIS). Keywords: Histoplasma; Histoplasmosis; Polymerase chain reaction Resumo: Paciente masculino, 27 anos, portador de HIV, com quadro de histoplasmose cutânea disseminada. Terapia antirretroviral oral e anfotericina B por via EV (dose total acumulada 0,5g) foram introduzidas, verificando-se rápida cicatrização das lesões após duas semanas. A anfotericina B foi substituí-da por itraconazol (200mg/dia). O paciente interrompeu voluntariamente os tratamentos. A terapia antirretroviral foi reintroduzida, havendo aumento da contagem de células T CD4-positivas (No restante do texto, a autora usa o símbolo "+" (T CD4+) ao invés da palavra "positiva". O que fazer neste caso? Seguimos o padrão do restante do texto ou acatamos essa opção da autora no resumo?!). Neste momento, diagnosticou-se histoplasmose ganglionar. O aumento da contagem de células T CD4-positivas (de novo aqui), associado à redução da carga viral a níveis inferiores ao limite de detecção após a reintrodução da terapia antirretroviral, sugere que essa piora clínica paradoxal seja uma síndrome de restauração imune. Palavras-chave: Histoplasma; Histoplasmose; Reação em cadeia da polimerase

Unmasking histoplasmosis immune reconstitution inflammatory syndrome in a patient recently started on antiretroviral therapy

“…Nacher et al 20 described a higher incidence of disseminated histoplasmosis among patients that recently started on antiretroviral therapy, suggesting that this treatment can lead to unmasking IRIS. Passos et al 21 reported the case of paradoxical histoplasmosis IRIS following re-introduction of HAART in a Brazilian patient that voluntarily stopped his HAART and itraconazole prophylaxis. Breton et al 22 presented four patients with HIV-associated with unmasking and paradoxical disseminated histoplasmosis IRIS.…”

Paradoxical worsening of Emergomyces africanus infection in an HIV-infected male on itraconazole and antiretroviral therapy

“…The histopathological observation of few yeasts and abundant inflammatory response in the patient’s second skin biopsy (compared to the findings of abundant yeasts but little inflammation noted on the biopsy at initial presentation), combined with the observed clinical improvement with a regimen that included prednisone, suggest that a paradoxical IRIS (apparent clinical worsening of disease previously controlled upon immune recovery, e.g., ART-mediated CD4+ T-cell lymphocyte repletion) may have contributed to this presentation. Paradoxical IRIS has been reported for other systemic mycoses including cryptococcosis [ 9 ] and occasionally other endemic mycoses like histoplasmosis [ 10 , 11 ] and coccidioidomycosis [ 12 ].…”

Understanding Pathogenesis and Care Challenges of Immune Reconstitution Inflammatory Syndrome in Fungal Infections

“…Most cases have been described with H. capsulatum var. capsulatum in HIV patients [29,30,31], solid organ transplant recipients [32], and patients receiving TNFα inhibitors [33]. To our knowledge, only one case was described with H. capsulatum var.…”