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Is it recurrent cryptococcal meningitis or immune reconstitution inflammatory syndrome
International Journal of STD & AIDS, 09/01/09

Lodha A et al. – The authors report a case of a 45–year–old patient with a history of cryptococcal meningitis who was started on antiretroviral therapy. The patient presented four months later with complaints of fever and memory loss. Lumbar puncture revealed positive cryptococcal antigen and therefore the patient was treated for recurrent cryptococcal meningitis. Unfortunately, the patient did not improve even after two weeks. The diagnosis of immune reconstitution was made at this time and steroids were started.

Exclusive Author Commentary
Ankur Lodha, 09/06/09

Patients infected with human immunodeficiency virus are at risk for development of potentially fatal opportunistic infections. Although antiretroviral therapy (ART) has reduced morbidity and mortality of patients living with HIV, an interesting and intriguing phenomenon (immune reconstitution inflammatory syndrome - IRIS) is seen in a subset of patients when the immune system begins to improve. IRIS may result in enhanced inflammatory reaction against microbes in an effort to eradicate them. This may paradoxically present as resurgence of an infection. Our case illustrates this phenomenon. While patient initially improved with antifungal therapy for cryptococcal meningitis, the symptoms seemed to worsen after ART was begun and the CD4 began to rise. It is important to differentiate between recurrence of the disease and inflammation secondary to immune restoration as treatment modalities would differ. Diagnosis can be challenging and requires high clinical suspicion. One should analyze such a situation in the light of improvement in immune system evidenced by a rise of CD4 count and a reduction in viral load. Physicians who treat patients with AIDS are likely to encounter such conditions and should be cognizant of this phenomenon. More research is warranted in this field to improve diagnostic tests and preventive and therapeutic strategies for IRIS.

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