Síndrome de reconstitución inmune relacionado con meningitis por Cryptococco en una adolescente infectada con el virus de inmunodeficiencia humana
Palabras clave:
SÍNDROME INFLAMATORIO DE RECONSTITUCIÓN INMUNE, MENINGITIS CRIPTOCÓCICA, VIHResumen
El síndrome de reconstitución inmune (SIRI) es una complicación del tratamiento del virus de inmunodeficiencia humana (VIH) en pacientes que tenían previamente una alteración profunda de su sistema inmunitario. Se puede presentar bajo dos formas: como SIRI desenmascardor (unmasking syndrom) o paradójico. Se presenta el caso de una adolescente de 13 años en la que se hace diagnóstico de infección por VIH y no se pudo establecer la fuente de contagio. Al momento del diagnóstico, con una inmunosupresión severa se inicia el tratamiento con antirretrovirales y dentro de los dos meses de iniciado es hospitalizada por una meningitis criptocócica. Tratada con anfotericina, evoluciona favorablemente y se logra esterilizar el líquido cefalorraquídeo. Instala nuevamente síndrome de hipertensión endocraneana con elementos de irritación meníngea y convulsiones. Enviada a terapia intensiva se realizan corticoides a altas dosis y mejora, siendo dada de alta. Se interpreta el primer episodio de meningitis criptocócica como un SIRI desenmascarador. Esto es que se pusieron de relieve gérmenes viables pero que su presencia era desconocida. El segundo episodio se interpreta como SIRI paradójico; el hecho de que previamente tuviera el líquido cefalorraquídeo estéril y que mejorara con corticoides y sin antifúngicos corrobora el diagnóstico. El SIRI es un diagnóstico de presunción y no hay elementos de diagnóstico de certeza. Son los datos de la clínica en un paciente VIH inmunosuprimido y en el que se inicia el tratamiento de alta eficacia los que permiten el diagnóstico.
Citas
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(2) Autran B, Carcelain G, Li T, Blanc C, Mathez B, Tubiana R. Positive effects of combined antiretroviral therapy on CD4+T cell homeostasis and function in advanced HIV disease. Science 1997; 277(5322):112-6.
(3) Battegay M, Nüesch R, Hirschel B, Kaufmann G. Immunological recovery and antiretroviral therapy in HIV-1 infection. Lancet Infect Dis 2006; 6(5):280-7.
(4) Singh N, Perfect J. Immune reconstitution syndrome associated with opportunistic mycoses. Lancet Infect Dis 2007; 7(6):395-401.
(5) Shelburne SA 3rd, Hamill RJ, Rodriguez-Barradas MC, Greenberg SB, Atmar RL, Musher DW, et al. Immune reconstitution inflammatory syndrome: emergence of a unique syndrome during highly active antiretroviral therapy. Medicine (Baltimore) 2002; 81(3):213-27.
(6) French M, Price P, Stone S. Immune restoration disease after antiretroviral therapy. AIDS 2004; 18(12):1615-27.
(7) French MA, Mallal SA, Dawkins RL. Zidovudine-induced restoration of cell-mediated immunity to mycobacteria in immunodeficient HIV infected patients. AIDS 1992; 6(11):1293-7.
(8) French M. HIV/AIDS: immune reconstitution inflammatory syndrome: a repraisal Clin Infect Dis 2009; 48(1):101-7.
(9) Singh N, Lortholary O, Alexander BD, Gupta KL, John GT, Pursell K, et al. An immune reconstitution syndrome-like illness associated with Cryptococcus neoformans infection infection in organ transplant recipients. Clin Infect Dis 2005; 40(12):1756-61.
(10) Cheng VC, Yuen KY, Wong SS, Woo PC, Ho PL, Lee R, et al. Immunorestitution diseases in patients no infected with HIV. Eur J Clin Microbiol Infect Dis 2001; 20(6):402-6.
(11) Einsiedel L, Gordon DL, Dyer JR. Paradoxical inflammatory reaction during treatment of Cryptococcus neoformans var.gatii meningitis in an HIV- seronegative woman. Clin Infect Dis 2004; 39(8):e78-82.
(12) Bower M, Nelson M, Young AM, Thirlwell C, Newsom-Davis T, Mandalia S, et al. Immune reconstitution syndrome associated with Kaposi`s sarcoma. J Clin Oncol 2005; 23(22):5224-8.
(13) Kumarasamy N, Chaguturu S, Mayer KH, Solomon S, Yepthomi HT, Balakrishnan P, et al. Incidence of immune reconstitution syndrome in HIV/tuberculosis-coinfected patients after initiation of generic antiretroviral therapy in India. J Acquir Immune Defic Syndr 2004; 37(5):1574-6.
(14) Narita M, Ashkin D, Hollender ES, Pitchenik AE. Paradoxical worsening of tuberculosis following therapy in patients with AIDS. Am J Respir Crit Care Med 1998; 158(1):157-61.
(15) John L, Baalwa J, Kalimugogo P, Nabankema E, Castelnuovo B, Muhindo G, et al. Response to "Does immune reconstitution promote active tuberculosis in patients receiving highly active antiretroviral therapy?". AIDS 2005; 19(17):2049-50.
(16) French MA, Lenzo N, John M, Mallal SA, McKinnon EJ, James IR, et al. Immune restoration disease after the treatment of immunodeficient HIV- infected patients with highly active antiretroviral therapy. HIV Med 2000; 1(2):107-15.
(17) Jevtoviæ DJ, Salemoviæ D, Ranin J, Pesiæ I, Zerjav S, Djurkoviæ-Djakoviæ O. The prevalence and risk of immune restoration disease in HIV-infected patients treated with highly active antiretroviral therapy. HIV Med 2005; 6(2):140-5.
(18) Bourgarit A, Carcelain G, Martinez V, Lascoux C, Delcey V, Gicquel B, et al. Explosion of tuberculin-specific Th1-responses induces immune restoration syndrome in tuberculosis and HIV co-infected patients. AIDS 2006; 20(2):F1-7.
(19) Shelburne SA 3rd, Darcourt J, White AC Jr, Greenberg SB, Hamill RJ, Atmar RL, et al. The role of immune reconstitution inflammatory syndrome in AIDS-related Cryptococcus Neoformans disease in the era of highly active antiretroviral therapy. Clin Infect Dis 2005; 40(7):1049-52.
(20) McCombe JA, Auer RN, Maingat FG, Houston S, Gill MJ, Power C. Neurologic immune reconstitution inflammatory syndrome in HIV/AIDS: outcome and epidemiology. Neurology 2009; 72(9):835-41.
(21) Asselman V, Thienemann F, Pepper DJ, Boulle A, Wilkinson RJ, Meintjes G, et al. Central nervous system disorders after starting antiretroviral therapy in South Africa. AIDS 2010; 24(18):2871-6.
(22) Puthanakit T, Oberdorfer P, Akarathum N, Wannarit P, Sirisanthana T, Sirisanthana V. Immune reconstitution syndrome after highly active antiretroviral therapy in HIV-infected thai children. Pediatr Infect Dis J 2006; 25(1):53-8.
(23) Tangsinmankong N, Kamchaisatian W, Lujan-Zilbermann J, Brown CL, Sleasman JW, Emmanuel PJ. Varicella zoster as a manifestation of immune restoration disease in HIV-infected children. J Allergy Clin Immunol 2004; 113(4):742-6.
(24) Johnson T, Nath A. Immune reconstitution inflammatory syndrome and the central nervous system. Curr Opin Neurol 2011; 24(3):284-90.
(25) Müller M, Wandel S, Colebunders R, Attia S, Furrer H, Egger M, et al. Immune reconstitution inflamatory syndrom in patients starting antiretroviral therapy for HIV infection: a systematic review and meta-analysis. Lancet Infect Dis 2010; 10(4):251-61.
(26) Price P, Morahan G, Huang D, Stone E, Cheong KY, Castley A, et al. Polymorphisms in cytokine genes define subpopulations of HIV-1 patients who experienced immune restoration diseases. AIDS 2002; 16(15):2043-7.
(27) Price P, Keane NM, Stone SF, Cheong KY, French MA. MHC haplotyoes affect the expression of opportunistic infections in HIV patients. Hum Immunol 2001; 62(2):157-64.
(28) Singh N, Perfect JR. Immune reconstitution syndrome associated with opportunistic mycoses. Lancet Infect Dis 2007; 7(6):395-401.
(29) Lortholary O, Fontanet A, Mémain N, Martin A, Sitbon K, Dromer F, et al. Incidence and risk factors of immune reconstitution inflamatory syndrome complicating HIV-associated cryptococcosis in France. AIDS 2005; 19(10):1043-9.
(30) Mofenson LM, Brady MT, Danner SP, Dominguez KL, Hazra R, Handelsman E, et al. Guidelines for the Prevention and Treatment of Opportunistic Infections among HIV-exposed and HIV-infected children: recommendations from CDC, the National Institutes of Health, the HIV Medicine Association of the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the American Academy of Pediatrics. MMWR Recomm Rep 2009; 58(RR-11):1-166.
(31) World Health Organization. Rapid advice: diagnosis, prevention and management of cryptococcal disease in HIV-infected adults, adolescents and children. Geneva: WHO, 2011. Disponible en: http://www.who.int/hiv/pub/cryptococcal_disease2011/en/. Consulta: 13 diciembre2011
(32) Quian J, Picón T, Galazka J, Gutiérrez S, Cafferata ML, Rodríguez I, et al. Síndrome de Inmunodeficiencia Adquirida en niños. Formas graves de enfermedad por BCG. Rev enfermedades infecc ped 2000; 14(54):62-7.
(33) Hesseling AC, Marais BJ, Gie RP, Schaaf HS, Fine PE, Godfrey-Faussett P, et al. The risk of disseminated Bacille Calmette-Guérin (BCG) disease in HIV-infected children. Vaccine 2007; 25(1):14-8.
(34) Hesseling AC, Rabie H, Marais BJ, Manders M, Lips M, Schaaf HS, et al. Bacille Calmette-Guérin vaccine-induced disease in HIV-infected an HIV- uninfected children. Clin Infect Dis 2006; 42(4):548-58.
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Publicado
2012-09-30
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1.
Quian J, Gutiérrez S, González V. Síndrome de reconstitución inmune relacionado con meningitis por Cryptococco en una adolescente infectada con el virus de inmunodeficiencia humana. Rev. Méd. Urug. [Internet]. 30 de septiembre de 2012 [citado 26 de diciembre de 2024];28(3):215-20. Disponible en: https://revista.rmu.org.uy/index.php/rmu/article/view/343
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