Life-threatening exacerbation of Kaposi's sarcoma after prednisone treatment for immune reconstitution inflammatory syndrome

Volkow, Patricia; Cornejo, Patricia; Zinser, Juan W; Ormsby, Christopher E.; Reyes‐Terán, Gustavo

doi:10.1097/qad.0b013e3282f4f223

Cited by 45 publications

(35 citation statements)

References 14 publications

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“…6 KS has also been documented to progress when high-dose steroids have been instituted to treat IRIS to non-KS antigens. 7 However, marked obstructive hepatitis in the context of IRIS has not to our knowledge been reported previously. In a series of liver postmortem histology in the pre-ART era, KS was found in 6/42 specimens.…”

Section: Discussionmentioning

confidence: 89%

Immune reconstitution inflammatory syndrome Kaposi sarcoma in the liver manifesting as acute obstructive hepatitis: another potential role for montelukast?

Read¹,

Lucas²,

Morris

et al. 2013

Int J STD AIDS

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Section: Discussionmentioning

confidence: 89%

Immune reconstitution inflammatory syndrome Kaposi sarcoma in the liver manifesting as acute obstructive hepatitis: another potential role for montelukast?

Read¹,

Lucas²,

Morris

et al. 2013

Int J STD AIDS

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“…Management of KS-IRIS has not been studied in controlled trials, but as opposed to some cases of Mycobacterium infection and cryptococcosis [9], corticosteroids are contraindicated in KS-IRIS, since it may further exacerbate KS lesions due to the synergy of cytokines with glucocorticoid receptors in KS spindle cells [22, 44, 45]. Herpes virus-specific immune reconstitution and the antiviral effect of combined cART plus chemotherapy has been recently documented with a trend toward better clinical outcome with cART plus chemotherapy compared with cART alone [46].…”

Section: Discussionmentioning

confidence: 99%

“…We included follow-up data up to June 30, 2013 provided the patients had >2 hospital-visits, and had not received systemic corticosteroids within the 2 months prior or concomitantly with the initiation of cART [22]. We obtained information on demographics, co-existence of other AIDS-defining events, cART regimen, CD4+ lymphocyte counts and viral load at HIV diagnosis and at 12 weeks follow-up.…”

Section: Methodsmentioning

confidence: 99%

Clinical characteristics, predictors of immune reconstitution inflammatory syndrome and long-term prognosis in patients with Kaposi sarcoma

et al. 2017

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ObjectiveTo investigate the predictive factors for the development of Kaposi sarcoma-related immune reconstitution inflammatory syndrome (KS-IRIS) and long-term prognosis in patients starting combined antiretroviral therapy (cART).MethodsWe studied a retrospective-cohort of consecutive antiretroviral-naïve patients with KS initiating cART from January 2005 to December 2011 and followed through June 2013. KS-IRIS was defined as ≥2 of the following: abrupt increase in number of KS lesions, appearance or exacerbation of lung-opacities or lymphedema, concomitantly with an increase in CD4+ cell-count ≥50 cells/mm3 and a decrease of >1 log in viral-load once started cART. We compared individuals who met KS-IRIS criteria with those that did not and described the long-term follow-up.ResultsWe included 89 patients, 88 males; 35 (39%) developed KS-IRIS at a median of 10 weeks (IQR 4–16). KS-IRIS patients had more pulmonary-involvement (60% vs. 16.6% of patients; p < 0.0001), eight died attributed to pulmonary-KS. Thrombocytopenia <100,000/mm3 at follow-up occurred in 36% of KS-IRIS vs. 4% in non-KS-IRIS patients (p = 0.0002), 45% KS-IRIS patients with thrombocytopenia died, non without KS-IRIS. Chemotherapy (bleomicyn–vincristine) was more frequently prescribed in KS-IRIS patients (88.6% vs. 29.6%) with no differences in outcome; 80% of all patients achieve KS complete remission, 52% of them never received chemotherapy. No difference between groups in the long-term follow-up (mean 52.4 ± 27.4 months) was found, only one patient developed a secondary malignancy (1.12%).ConclusionsLung-involvement was predictive of IRIS development. Thrombocytopenia in KS-IRIS patients at week 12 follow-up after cART initiation was associated with high mortality. Over a third of patients with KS achieve remission without chemotherapy. Individuals that survive the initial period of KS-IRIS adhere to cART had a good long-term prognosis.Electronic supplementary materialThe online version of this article (doi:10.1186/s12981-017-0156-9) contains supplementary material, which is available to authorized users.

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“…Although effective in case management [131], use in prevention does not appear well justified. Use of corticosteroids in HIV-infected people is associated with a range of adverse effects including reactivation of herpes virus infections, exacerbation of KS and precipitating other infections, including strongyloidiasis [131,139-141]. Given that paradoxical TB-IRD develops in around one in five patients with a TB diagnosis prior to ART, it would mean that four out of five patients would be unnecessarily exposed to the adverse effects of corticosteroids.…”

Section: Prevention: Pharmacological Interventionsmentioning

confidence: 99%

Pathogenesis and prevention of immune reconstitution disease during antiretroviral therapy

Lawn

Meintjes

2011

Expert Review of Anti-infective Therapy

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The risks of unmasking and paradoxical forms of immune reconstitution disease in HIV-infected patients starting antiretroviral therapy (ART) are fuelled by a combination of the late presentation of patients with advanced immunodeficiency, the associated high rates of opportunistic infections (OIs) and the need for rapid initiation of ART to minimize overall mortality risk. We review the risk factors and our current knowledge of the immunopathogenesis of immune reconstitution disease, leading to a discussion of strategies for prevention. Initiation of ART at higher CD4 counts, use of OI-preventive therapies prior to ART eligibility, intensified screening for OIs prior to ART initiation and optimum therapy for OIs are all needed. In addition, use of a range of pharmacological agents with immunosuppressive and immunomodulatory activity is being explored.

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Life-threatening exacerbation of Kaposi's sarcoma after prednisone treatment for immune reconstitution inflammatory syndrome

Cited by 45 publications

References 14 publications

Immune reconstitution inflammatory syndrome Kaposi sarcoma in the liver manifesting as acute obstructive hepatitis: another potential role for montelukast?

Immune reconstitution inflammatory syndrome Kaposi sarcoma in the liver manifesting as acute obstructive hepatitis: another potential role for montelukast?

Clinical characteristics, predictors of immune reconstitution inflammatory syndrome and long-term prognosis in patients with Kaposi sarcoma

Pathogenesis and prevention of immune reconstitution disease during antiretroviral therapy

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