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La gestione della persona immigrata con coinfezione parte II

Tubercolosi , HIV e migrazione: una reale emergenza ?. SESSIONE II -ˇ HIV e Tubercolosi nella persona immigrata. La gestione della persona immigrata con coinfezione parte II. Miriam Lichtner Dipartimento di Malattie Infettive e Sanità Pubblica Sapienza Università di Roma Polo Pontino

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La gestione della persona immigrata con coinfezione parte II

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  1. Tubercolosi, HIV e migrazione: una reale emergenza? SESSIONE II -ˇ HIV e Tubercolosi nella persona immigrata La gestione della persona immigrata con coinfezioneparte II Miriam Lichtner Dipartimento di Malattie Infettive e Sanità Pubblica Sapienza Università di Roma Polo Pontino Componente dell’ Italian National Focal Point – InfectiousDiseases and Migrant”

  2. Sergej • Dopo 4 mesi di ART e 2 di anti-TB (11/04/07): febbre elevata con sospetto di IRIS, inizia deltacortene e streptomicina • CD4+ 98/mmc, HIV-RNA<50 • Dimissione 26/4/07 controllo DH dopo 1 sett

  3. IRIS:Immune Reconstitution Inflammatory Syndrome

  4. Quadri storici di IRIS • Reazioneparadossalenella TB dopoiniziotrattamento • Reazioneinfiammatorianeipz con lebbra in trattamento • Recupero del sist. immune dopotrapianto di midollo e chemioterapia • Rispostaatipicainfiammatoriaaimicobatteriatipicineipz in terapia con AZT (anni 80)

  5. Immune suppression/deficiency Impaired pathogen-specific immunity Quantitative immune defects CD4 counts Qualitative/functional immune defects Response to recall antigens HIV replication Immune activation OI Immune Reconstitution HAART Qualitative/functional immune defects Reversal of anergy Lymphocyte proliferative capacity Quantitative immune defects Redistribution, death (HIV-, activation-induced), production (peripheral expansion and thymic) Improved pathogen-specific immunity Improved immune control HIV replication Immune activation Antiretroviral Therapy Improves Qualitative and Quantitative Immune Defects Migueles, Buenos Aires 2003

  6. Immune reconstitution inflammatory syndrome Source: GHTM, Chennai

  7. Defining IRIS Source: CID J 2006;(1 June) 42: 1639-46

  8. Defining IRIS • Proposed criteria for the diagnosis of IRIS • HIV positive • Receiving HAART • Decrease in HIV-1 RNA level from baseline • Increase in CD4 cells from baseline(may lag HIV-1 RNA decrease) • Clinical symptoms consistent with inflammatory process • Clinical course NOT consistent with: • Expected course of previously diagnosed OI • Expected course of newly diagnosed OI • Drug toxicity • Source: Journal of Antimicrobial Chemotherapy (2006) 57, 167-170; • Samuel A. Shelburne, Martin Montes and Richard J.Hamill

  9. Defining IRIS: Major Criteria • Previous diagnosis of AIDS • Concurrent Antiretroviral Therapy; Increase in CD4 count and Decrease in plasma vireamia by > 1 log copies/ml • Atypical presentation of ‘opportunistic infection or tumor’ i.e. • localized disease or • exaggerated inflammation or • atypical inflammatory response or • worsening of pre existing disease. • Symptoms consistent with infectious/inflammatory condition • Symptoms not explained by normal course of previous or new OI or side effect of ART Source: Battegay and Drechsler; Current Opinion in HIV and AIDS; 2006, 1; 56-61

  10. Defining IRIS: Minor Criteria • Increase in CD4 cell count • Increase in measured specific immune response • Spontaneous resolution of symptoms without specific therapy Source: Battegay and Drechsler; Current Opinion in HIV and AIDS; 2006, 1; 56-61

  11. Onset of IRIS Source: AIDS 2005, Vol 19 No4 ;399-406, Samuel A. Shelburne et al

  12. Risk factors • Risk factors at base line: • Lower CD4 count prior to start of ART • Higher HIV-1 RNA levels at base line • Initiating ART in close proximity to starting therapy for an OI • Response to therapy & the development of IRIS: • Rapid fall in HIV-1 RNA level during the first 3 months of therapy • Source: Journal of Antimicrobial Chemotherapy (2006) 57, 167-170;Samuel A. Shelburne, Martin Montes and Richard J.Hamill

  13. Risk factors for IRIS Microbial antigens Host susceptibility CD4< 50 Adapted from French et al, 2004

  14. Management • Mild form (with ongoing ART) • Observation • Localized IRIS (with ongoing ART) • Local therapy such as minor surgical procedures for lymph node abscesses • Most of the situations (with ongoing ART) • Unmasking &/or Recognition of ongoing infections >> Antimicrobial therapy to reduce the antigen load of the triggering pathogen; • Reconstituting immune reaction to non-replicating antigens >> no antimicrobial therapy. Short term therapy with corticosteroids or non-steroidal anti inflammatory drugs to reduce the inflammation.

  15. Management • Temporary cessation of ART has to be considered if potentially life threatening forms of IRIS develop

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