The study of immune reconstitution inflammatory syndromeIRIS in resource limited settings

1
The study of immune reconstitution inflammatory
syndrome(IRIS) in resource limited settings

• Dr Milind Bhrushundi M D
• Dr Pradeep Mishra M D
• Lata Mangeshkar Hospital Nagpur
• India

2
Objectives

• To assess proportion of patients developing IRIS
  after initiation of antiretroviral therapy
  attending Lata Mangeshkar Hospital (LMH) in
  Nagpur, India
• To describe pattern of IRIS
• To identify factors associated with development
  of IRIS

3
Methods

• 720 consecutive patients attending LMH, Nagpur
  between 2002- 2005 were recruited
• Patients were examined clinically investigated
  for presence of OI before initiating ART
  treated wherever necessary
• Since patients had to pay for complete/ part of
  tests, package of investigations differed.

4
Investigations
5
Case definition

• Appearance of new OI or deterioration in patients
  treated for OI who showed signs symptoms of
  clinical improvement initially within 3 months of
  initiating ART with increase in CD4 counts
• Worsening of the symptoms without significant
  rise in CD4 T-helper were excluded by the
  definition .

6
Demographic profile n720

• Age- Mean- 35.6 years ( range 21-75 yrs)
• Sex- 582 Males and 138 females
• Baseline Investigations Essential 230 (32)
  Optional -366 (51), Ideal - 124 (17)
• Of them, 549 (76) were ARV-naïve.
• Of the 171 ARV-experienced patients, 26 (17) had
  received two ARVs 143 (83) received 3 ARVs
• Of the ARV-naïve patients, 71 ( 13) received
  EFV-based regime remaining received NVP-based
  regimen.

7
Results

• Univariate analysis revealed
• IRIS was not associated with any age group
  (p0.06)
• However, females were found to be less likely to
  develop IRIS (p0.001)
• Patients who were offered essential (minimal
  tests) package at baseline were more likely to
  develop IRIS (p 0.001)

8
Results

• Patients with CD4 lt 50 cells between 50-100
  cells/cm were likely to develop IRIS (p0.0001)
• Patients with past history or current OI were
  more likely to develop IRIS (p0.0001)
• Patients with CD4 counts of lt50 cells were 40
  times more likely to develop IRIS. (p .0001),CD4
  counts of lt100 cells were 12 times more likely to
  develop IRIS. (p 0.0001)

9
Results

• Multivariate analysis revealed that the
  likelihood of development of IRIS was
• Males were 3.1 ( 95 CI 0.92-11.1) times more
  likely to develop IRIS than females. (P0.06)
• Patients with CD4 counts of lt50 cells were 4.3
  times more likely to develop IRIS. (p 0.0001)
• Those who could only afford a minimal (essential)
  package of base line laboratory tests were 1.4
  times more likely to develop IRIS (p0.05)

10
Patterns of IRIS
11
Patterns of TB IRIS
12
(No Transcript)
13
(No Transcript)
14
(No Transcript)
15
(No Transcript)
16
(No Transcript)
17
DIAGNOSIS OF IRIS CASES PRIOR TO ART
18
CORRELATION OF AKT REGIMEN
19
Treatment of IRIS

• TB-DOTS,NVP changed to EFV
• PCP- TMP/SMX, Steroids used in 3 cases, one
  mortality
• Cryptococcal Meningitis-Amphotericin-B, one
  mortality, two had Amphotericin toxicity
• CMV retinitis- Rx not affordable-Optic Atrophy,
  otherwise normal.
• Hepatitis C- Pegylated interferon Ribavarin
• PML-ART, Still having neurological symptoms

20
FOLLOW-UP IRIS CASES
Mortality
21
Conclusions

• IRIS occurred in 9.4 patients initiated on ART
  in Nagpur India
• All those who have developed IRIS had prior
  history of OI
• Limited investigations prior to initiation of ART
  is associated with increased risk of IRIS
• Proportion of IRIS is less in Government run free
  ART clinic because of strict protocol for the
  investigation prior to ART .

22
Conclusion

• Proportion of cases is significantly high with
  low baseline CD4 counts(lt50)
• increase in CD4 cells was significantly high
  (192) with low CD4
• Tuberculosis continues to predominate in IRIS in
  India (in 54 cases)
• Need to educate the Physicians for proper
  ART(16.66 were on double drug therapy)

23
Thanks

• Dr R R Gangakhedkar
• Dr Suresh Ughade
• Dr Urmila Varadpande
• All My patients
• My wife and daughter
• Sanjeevan Nagpur- India