Immune reconstitution inflammatory syndrome in a patient with HIV presenting as severe mixed haemolytic anaemia

Abstract

A patient with a delayed diagnosis of vertically transmitted HIV presented with a rare form of severe warm and cold (mixed) autoimmune haemolytic anaemia, six months after starting antiretroviral therapy. The CD4 count had responded rapidly to introduction of antiretroviral therapy, rising from 5 cells/µL to 93 cells/µL over the course of six months. The haemolysis was resistant to immunoglobulin therapy, eventually responding to corticosteroids. On careful scrutiny of the case, we found the features to be in keeping with immune reconstitution inflammatory syndrome; thorough investigations revealed no other trigger for haemolysis in this case.

Effect of the relationship between anaemia and systemic inflammation on the risk of incident tuberculosis and death in people with advanced HIV: a sub-analysis of the REMEMBER trial

“…By analysing the systemic inflammatory profile of our cohort, we uncovered, in agreement with other previously reported investigations, that the severity of anaemia was linked to increased inflammation. 16 , 25 , 26 , 27 Innate inflammatory (IL-6, IL-8, and TNF), Th1 (IFN-γ, IL-2, IL-12p40), and Th2 (IL-13 and VEGF-A) cytokine concentrations increased following the degree of anaemia severity. Individuals with severe inflammation commonly present with cytopenia, and in some cases develop severe syndromes with an overproduction of IFN-γ, IL-2, IL-12, and TNF, by activated Th1 cells and macrophages.…”

Association between severe anaemia and inflammation, risk of IRIS and death in persons with HIV: A multinational cohort study

“…In agreement with others, we found an augmented inflammation tracking the severity of the anaemia. 10 , 19 , 20 , 21 …”

Sequential occurrence of Graves’ disease and immune thrombocytopenic purpura as manifestations of immune reconstitution inflammatory syndrome in an HIV-infected patient

“…Although thrombocytopenia is a common finding in patients with HIV, with an incidence of 30%, ITP is rare. 2,[5][6][7][8] ITP presenting as IRIS has only been described in three previous case reports. 6,9,10 In our case, ITP occurred six years after initiation of antiretrovirals and six years of virological suppression.…”