Paradoxical immune reconstitution inflammatory syndrome due to toxoplasmic encephalitis: two cases and review of initiation of antiretroviral timing in toxoplasmic encephalitis IRIS

Abstract

Toxoplasma encephalitis immune reconstitution inflammatory syndrome (TE-IRIS) is rare and usually occurs in an unmasking, rather than paradoxical form. To the best of our knowledge, only two cases of paradoxical TE-IRIS and nine cases of unmasking TE-IRIS have been previously described. We present two additional cases of histopathology-consistent paradoxical TE-IRIS, after early initiation of antiretroviral therapy (ART), and review the literature on TE-IRIS. Three of the four reported cases of paradoxical TE-IRIS were associated with early (within one week) initiation of ART, an issue that was not addressed in the 2009 US Department of Health and Human Services guidelines for the treatment of opportunistic infections.

New insights into immune reconstitution inflammatory syndrome of the central nervous system

“…The clinical features, estimated rates of IRIS occurrence and risk factors associated with these infections were recently reviewed by Bahr and colleagues (34**). Other opportunistic infections, such as Varicella Zoster Virus (41-43), Cytomegolovirus (44, 45), Candida species (46) and Toxoplasma gondii (47-49) are associated with CNS-IRIS, but contribute to the frequency of disease at much reduced rates as compared to cryptococcal meningitis (CM) and tuberculosis (TB) infections. Studies on the prevention of CNS-IRIS suggest that a one-size-fits-all approach is not appropriate once a patient is immune compromised.…”

Toxoplasmosis-associated IRIS involving the CNS: a case report with longitudinal analysis of T cell subsets

“…All these criteria were observed in the case described herein. To better understand the clinical features of paradoxical toxoplasmosis-associated CNS-IRIS, we summarized the information of the previously reported 5 cases [15–18] (Table 1) and compared with the new reported case.…”

“…Despite the significant incidence of cerebral toxoplasmosis, only five paradoxical CNS-IRIS cases associated to T. gondii have been previously described (Table 1) [15–18]. Similarly to other IRIS conditions, there is no consensual treatment for toxoplasmosis-associated IRIS and prognosis is poor [5].…”

“…CD8 + predominant lymphocytic infiltrates. Treatment: Corticosteroids. Outcome: Clinical improvement without complete resolution.[18]Case 5 Male, 51 yo At diagnosis: AIDS previously diagnosed, not on HAART or prophylaxis. Manifestations: Unsteady gait, left upper extremity weakness, headaches, weight loss and fever for 2 weeks. Brain MRI: Multiple ring-enhancing lesions in his fronto parietal region. Treatment: ATT, HAART. Presentation: After an initial improvement, there was progression of neurological symptoms around 2 weeks after treatment initiation. CSF studies: 6 WBC/mm 3 (100% lymphocytes); no malignant cells. Brain MRI: No significant change.…”

“…CD8 + predominant lymphocytic infiltrates. Treatment: Corticosteroids. Outcome: Clinical improvement.[18]Cases are ordered by year of publication. a All case descriptions reported infection by Toxoplasma gondii , except for case 2 (no species was specified).…”