Immune reconstitution inflammatory syndrome‐associated Graves disease in HIV‐infected patients: clinical characteristics and response to radioactive iodine therapy

Abstract

Objectives We aimed to describe the clinical characteristics and the response to radioactive iodine (RAI) treatment of immune reconstitution inflammatory syndrome‐associated Graves disease (IRIS‐GD) in comparison to Graves disease (GD) seen in HIV‐uninfected patients. Methods We retrospectively reviewed the medical records of patients treated with RAI for GD. We obtained clinical, biochemical and HIV‐related information of patients from their medical records. We compared patient characteristics and response to RAI treatment between patients with IRIS‐GD and GD seen in HIV‐uninfected patients. Results A total of 253 GD patients, including 51 patients with IRIS‐GD, were included. Among IRIS‐GD patients, CD4 cell nadir was 66 cells/µL (range: 37–103) with a peak HIV viral load of 60 900 copies/mL (range: 36 542–64 500). At the time of diagnosis of IRIS‐GD, all patients had a completely suppressed HIV viraemia with a CD4 cell count of 729 cells/µL (range: 350–1279). The median interval between the commencement of HIV treatment and the onset of GD was 63 months. At 3 months follow‐up, the proportion of patients with IRIS‐GD achieving a successful RAI treatment outcome (euthyroid/hypothyroid state) was lower than that of HIV‐uninfected patients (35.3% vs. 63.4%, respectively; p < 0.001). The response rate remained lower (60.8%) among patients with IRIS GD than among HIV‐uninfected GD patients (80.2%, p = 0.004) at 6 months follow‐up. After correcting for differences in age, gender and pre‐treatment thyroid‐stimulating hormone level, there was no significant difference in RAI treatment response between the two groups. Conclusions After correcting for possible confounders, the response to RAI treatment was not different between patients with IRIS‐GD and GD in HIV‐uninfected patients.

Molecular Imaging of Tuberculosis

“…The institution of ART in these severely immunosuppressed patients often leads to the apparent worsening of existing opportunistic conditions and the appearance of new inflammatory/infectious conditions due to an exaggerated immune response to foreign and self-antigens, the so-called immune reconstitution and inflammatory syndrome (IRIS). 81,82 The institution of ART in patients on ATT for TB may lead to the paradoxical worsening of disease symptoms and image findings. 83 FDG PET/CT obtained in these patients for interim response assessment during the process of IRIS may show worsening of disease (increased FDG avidity in lesions, new pulmonary and extrapulmonary lesions).…”

Thyroid Diseases and Thyroid Asymptomatic Dysfunction in People Living With HIV

“…Although the pathogenic mechanism of GD-IRIS is not completely known, it seems to be a consequence of an immunoregulatory disequilibrium, characterized by thymic enlargement, failure of thymic deletion of autoreactive T-cells, persistence of T-cell receptor excision circle levels in CD4 and lymphocytes T CD8+ (CD8), and high circulating levels of naïve CD8 [ 59 , 65 ]. It seems that immune reconstitution promotes a profile shift in cytokines production from TH2 to TH1 types, permissive for the development of autoimmunity events [ 66 ].…”

“…Radioactive iodine (RAI) treatment is an increasing therapy used either as first-line treatment or as an alternative treatment in patients who do not tolerate or respond to medical therapy. RAI treatment is based on the principle that the thyroid gland entraps iodine and uses it for THs production; thus, once inside the thyroid follicular cells, RAI releases energetic beta particles, leading to the destruction of the follicular cells [ 65 ]. A recent retrospective study showed that there is no difference in response to RAI treatment between PLWH with IRIS-GD and GD in HIV-uninfected patients [ 65 ].…”

“…RAI treatment is based on the principle that the thyroid gland entraps iodine and uses it for THs production; thus, once inside the thyroid follicular cells, RAI releases energetic beta particles, leading to the destruction of the follicular cells [ 65 ]. A recent retrospective study showed that there is no difference in response to RAI treatment between PLWH with IRIS-GD and GD in HIV-uninfected patients [ 65 ]. Surgical approach is a valid option; however, it can determine hypoparathyroidism or laryngeal nerve damage [ 60 ].…”

Hyperthyroidism with papillary thyroid carcinoma in HIV: Case report and literature review

“…In the era of HAART (highly active retroviral therapy), the autoimmune diseases of HIV infected patients after treatment mainly occur at the phase of immunological recovery [ 1 ]. The inflammatory syndrome related Graves' disease, occurs after HIV infected patients begin immune reestablishment on antiretroviral therapy at an advanced stage of the disease [ 2 ]. The reason may be that the expansion of naive T cells and primary transplanted CD4T cells and the increase of autoantibody titers lead to the development of organ-specific autoimmune diseases [ 3 ].…”