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Chapter 34 : Paradoxical Reactions and the Immune Reconstitution Inflammatory Syndrome

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Abstract:

Paradoxical reactions may occur in up to 25% of patients treated for tuberculous lymphadenitis, characterized by new or enlarging lymphadenopathy, which may be tender or painful. The frequency of paradoxical reactions in this setting is unknown but was 50% (4 of 8) in one series. Corticosteroids are probably indicated for severe pleural and most central nervous system (CNS) paradoxical reactions to manage symptoms and CNS edema. Although the heightened granulomatous response from highly active antiretroviral therapy (HAART) would help clear mycobacterial organisms, the granulomatous inflammation itself may cause significant damage, thus resulting in immune reconstitution inflammatory syndrome (IRIS). Management of IRIS due to complex disease should be directed at treating the infection and managing symptoms. The major difference is that the antigens responsible for granulomatous inflammation in tuberculosis (TB) are peptides resulting from digestion and processing of the microorganism, whereas in sarcoidosis the putative antigens are unknown. New-onset sarcoidosis is rare in HIV-infected patients. This can probably be explained by the HIV-induced alteration in cell-mediated immunity described. However, several cases of sarcoidosis have been reported after initiation of HAART. The pathogenesis of this condition is likely to be very similar to the paradoxical reactions seen in HAART-treated HIV-infected patients with TB.

Citation: Church P, Judson M. 2011. Paradoxical Reactions and the Immune Reconstitution Inflammatory Syndrome, p 509-521. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch34

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Figure 1.

Chest X ray before (A) and 3 months after (B) initiation of antiretroviral therapy, demonstrating a new left hilar mass (arrow). Chest computed tomography scan (C) demonstrates a 2.0- by 2.0- by 2.5-cm heterogeneous mass just anterior to the left upper lobe bronchus. The lung parenchyma is normal, and no mediastinal adenopathy is present.

Citation: Church P, Judson M. 2011. Paradoxical Reactions and the Immune Reconstitution Inflammatory Syndrome, p 509-521. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch34
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Tables

Generic image for table
Table 1.

Clinical features: TB, paradoxical reaction and IRIS

Citation: Church P, Judson M. 2011. Paradoxical Reactions and the Immune Reconstitution Inflammatory Syndrome, p 509-521. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch34
Generic image for table
Table 2.

Incidence: TB, paradoxical reaction, and IRIS

Citation: Church P, Judson M. 2011. Paradoxical Reactions and the Immune Reconstitution Inflammatory Syndrome, p 509-521. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch34
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Table 3.

Sarcoidosis and IRIS case reports

Citation: Church P, Judson M. 2011. Paradoxical Reactions and the Immune Reconstitution Inflammatory Syndrome, p 509-521. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch34

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