Toxoplasmic encephalitis IRIS in HIV-infected patients: a case series and review of the literature
Résumé
Background: Toxoplasmic encephalitis associated with immune reconstitution inflammatory syndrome (TE-IRIS) is rarely described. Methods: To identify TE-IRIS cases, we performed a retrospective study of all HIV-infected patients diagnosed with TE in our unit between January 2000 and June 2009, and a review of published cases. Results: Three patients out of our 65 TE cases, together with six from the literature, fulfilled unmasking TE-IRIS definition. None fulfilled paradoxical TE-IRIS definition. TE occurred within a median time of 48.5 days [IQ25-75 21-56] after starting antiretroviral therapy. Cases did not have distinctive clinical nor neuroimaging features from TE occurring without immune reconstitution. However: i) Cases occurred at a median CD4 lymphocytes count of 222/µL [IQ25-75 160-280], ii) TE occurred in five patients who were supposed to take an effective chemoprophylaxis, iii) Two patients had a brain biopsy showing an intense angiocentric inflammatory infiltrates with predominantly CD8 lymphocytes, iv) In one patient, the abnormal length of evolution under treatment might be due to the heightened immune response. Conclusion: Although rare, unmasking TE-IRIS exists and might occur despite effective prophylaxis and an unusually high CD4 lymphocytes count. IRIS does not modify TE diagnosis and treatment but might extend its clinical course.
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