D89.3 + (Y41.5 + B24)
DESCRIPTION
IRIS occurs when improving immune function unmasks a previously occult opportunistic disease, which has an unusual inflammatory presentation (“unmasking IRIS”) or causes paradoxical deterioration of an existing opportunistic disease (“paradoxical IRIS”). IRIS is more common in patients with advanced HIV disease, particularly those with a CD4 count <100 cells/mm3. IRIS nearly always presents during the first 3 months of ART, with the median time of onset being about two weeks. The diagnosis of paradoxical IRIS is often difficult as new opportunistic diseases or drug resistance of the organism causing the opportunistic infection need to be excluded.
TB is the commonest opportunistic disease involved in IRIS reactions in South Africa. Paradoxical TB IRIS presents as recurrence of TB symptoms/signs, or worsening, or new manifestations. The commonest presentation is with enlarging lymph nodes, often with extensive caseous necrosis. Lung infiltrates or effusions may worsen or develop. It is important to exclude multi-drug resistance in all patients suspected with paradoxical TB IRIS.
Other common IRIS manifestations include:
- Inflammatory reactions to skin diseases, especially acne and Kaposi’s sarcoma.
- Worsening cryptococcal meningitis.
- Flares of hepatitis B or C.
GENERAL MEASURES
Counseling is important to ensure that the patient understands that IRIS does not mean failure of ART.
Management of IRIS is mainly symptomatic, e.g. aspiration of TB lymph nodes or effusions.
Continue ART and therapy for the opportunistic infection.
MEDICINE TREATMENT
For pain and fever:
- Paracetamol, oral, 1 g 4–6 hourly when required.
- Maximum dose: 15 mg/kg/dose.
- Maximum daily dose: 4 g in 24 hours.
OR
- NSAID, e.g.:
- Ibuprofen, oral, 400 mg 8 hourly with meals.
Treating severe IRIS manifestations (e.g. compression of major structures by enlarging lymph nodes, expanding CNS tuberculomata, worsening meningitis):
- Corticosteroids (intermediate-acting) e.g.:
- Prednisone, oral, 1.5 mg/kg daily for 2 weeks.
- Then 0.75 mg/kg daily for 2 weeks.
Preventing severe IRIS in high risk patients (CD4 ≤100 cells/mm^3) and had antituberculosis treatment for <30 days before initiating ART:
- Corticosteroids (intermediate-acting) e.g.:
- Prednisone, oral, 40 mg daily for 2 weeks.
- Then 20 mg daily for 2 weeks.
Note: Do not use steroids in patients with Kaposi sarcoma.