Varicella Zoster Virus Central Nervous System Immune Reconstitution Inflammatory Syndrome Presenting in a Child

Iro, Mildred A; Kirkham, Fenella J.; Macdonald, Jason H. M.; Tebruegge, Marc; Faust, Saul N; Patel, Sanjay

doi:10.1097/inf.0b013e31829aa4fc

Cited by 7 publications

(5 citation statements)

References 11 publications

(7 reference statements)

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“…There is no evidence from our data to suggest a link between stroke and antiretroviral therapy; in fact, there was a trend for atypical TCD to be more common in untreated patients. Protease inhibitors have been shown to have effects on carotid intimal thickness and endothelial‐derived arterial function, partly explained by the induction of a metabolic syndrome with insulin resistance.…”

Section: Discussioncontrasting

confidence: 69%

“…A T cell‐mediated vasculitis/perivasculitis has been recognized in children with HIV encephalopathy and concurrent ischaemic stroke . The metabolic and immune effects of antiretrovirals may confer additional stroke risk …”

mentioning

confidence: 99%

“…7 The metabolic and immune effects of antiretrovirals may confer additional stroke risk. 1,8 Transcranial Doppler (TCD) ultrasound enables noninvasive measurement of blood flow velocity in the basal cerebral arteries. Distal internal carotid artery (ICA)/middle cerebral artery (MCA) time-averaged maximum mean velocity (TAMMV) is rarely less than 50cm/s or more than 140cm/s in typically developing European 9 or African 10 children, while in those with sickle cell anaemia, an ICA/ MCA TAMMV less than 70cm/s or more than 190cm/s identifies vessel occlusion or stenosis.…”

mentioning

confidence: 99%

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Stroke transcranial Doppler in children with human immunodeficiency virus

Dlamini

Pohl

Eley

et al. 2020

Develop Med Child Neuro

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Aims To describe stroke syndromes and transcranial Doppler (TCD) findings in children with human immunodeficiency virus (HIV) and examine the associations between TCD and clinical and laboratory data. Method We enrolled 42 children (24 males, 18 females) with HIV (median age=7y 6mo; 2y 7mo–15y 6mo), with and without stroke who underwent a TCD examination of the anterior and posterior circulations to derive time‐averaged maximum mean velocity (TAMMV) measurements for comparison with previous studies. Clinical and laboratory variables were extracted from the medical records. Results Of the 42 children with HIV, five had right‐sided hemiparesis, three had chronic lung disease, two occurred post‐varicella infection, one after herpetic oral ulceration, and one had a poorly functioning left ventricle. Neuroimaging showed middle cerebral artery (MCA) TAMMV greater than 200cm/s, moyamoya‐like arteriopathy, left basal ganglia infarction with ipsilateral stenosis, hygroma consistent with venous thrombosis, and a hyperdense left MCA. Eight neurologically asymptomatic children had atypical TCD. The CD4 cell count was non‐significantly lower in 6 out of 30 children with atypical TCD (median=21.5; interquartile range=16.1–26.5) compared with the remainder (median=29; interquartile range=21.3–35.0; p=0.09). Interpretation A variety of stroke syndromes occur in children with HIV. TCD suggests atypical intracranial vessels and/or haemodynamics in some children with HIV infection, consistent with vasculopathy, possibly related directly to immunodeficiency and/or infection. What this paper adds A range of stroke syndromes are found in children with human immunodeficiency virus (HIV). Transcranial Doppler (TCD) velocities in HIV are commonly outside the range for typically developing children. TCD and neuroimaging data in children with HIV suggest intracranial vasculopathy as one mechanism for stroke. CD4 cell count is non‐significantly lower in children with HIV and atypical TCD.

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Section: Discussioncontrasting

confidence: 69%

mentioning

confidence: 99%

mentioning

confidence: 99%

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Stroke transcranial Doppler in children with human immunodeficiency virus

Dlamini

Pohl

Eley

et al. 2020

Develop Med Child Neuro

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“…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.…”

Section: Cns-iris In Association With Opportunistic Infectionmentioning

confidence: 99%

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

Johnson

Nath

2014

Current Opinion in HIV and AIDS

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Purpose of review To highlight the importance of immune reconstitution inflammatory syndrome (IRIS) affecting the brain in HIV-infected individuals in the absence of opportunistic infections. To describe the varied clinical manifestations, unifying pathophysiological features and discuss the principles of management of this syndrome. Recent Findings IRIS within the brain is commonly seen in patients with HIV infection upon initiation of antiretroviral drugs. The fulminant forms occur in the face of opportunistic infections or uncontrolled viral replication within the brain. In this case the enhanced immune response is targeted against the microbial agent, and the brain suffers bystander damage. Treatment requires the combination of the antimicrobial agent, continued antiretrovirals and in some cases corticosteroids. It is increasingly being recognized that despite adequate control of viral replication in the brain some patients develop a chronic form of T cell encephalitis which appears to be driven by continued production of HIV-Tat protein. In others the immune response may be targeted against the host antigens in the brain. Summary In patients with CNS-IRIS the use of corticosteroids and strategies that prevent T cell migration into the brain may be needed. Extreme caution is necessary if viral eradication strategies are to employed that involve activation of viral reservoirs, since these patients may be at risk for developing CNS-IRIS.

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“…Space will not allow discussion of other opportunistic infections (OI) that also demonstrate abnormal inflammatory responses, including tuberculosis, varicella and toxoplasmosis. 1-6 …”

Section: Introductionmentioning

confidence: 99%

Neurological immune reconstitution inflammatory response

Clifford

2015

Current Opinion in Neurology

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Purpose of review This manuscript reviews current reports about clinical aspects of immune reconstitution inflammatory responses (IRIS), with particular emphasis on IRIS in the setting of progressive multifocal leukoencephalopathy (PML) and to a lesser extent on cryptococcal meningitis (CM) and human immunodeficiency virus (HIV). Recent findings PML prognosis has been radically improved as it has become possible to provide immune reconstitution, while some remaining morbidity and mortality results from excess inflammation. Similar pathologic responses are seen less often, but remain clinically important in CM, and HIV. Early diagnosis and active management of PML results in optimal outcomes with survival of 75% or higher in multiple recent series. These finding apply both to natalizumab and HIV associated PML. CM is frequently complicated by IRIS, and early treatment with antifungal therapy preceding HIV therapy provides optimal outcomes. HIV IRIS is reduced by early therapy which is now recommended, but even on therapy, chronic dysregulated immune responses may play important roles in ongoing HAND which is common, as well as rare but more dramatic subacute encephalopathies. Summary The clinician must actively monitor and treat both OI and the inflammatory response that is essential to recovery but may itself augment pathology and injury.

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Varicella Zoster Virus Central Nervous System Immune Reconstitution Inflammatory Syndrome Presenting in a Child

Cited by 7 publications

References 11 publications

Stroke transcranial Doppler in children with human immunodeficiency virus

Stroke transcranial Doppler in children with human immunodeficiency virus

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

Neurological immune reconstitution inflammatory response

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