Antiretrovirals
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Fatal immune reconstitution syndrome in a patient with Candida meningitis: case report A 43-year-old man with HIV-infection and chronic Candida meningitis developed fatal immune reconstitution syndrome (IRIS) during treatment with highly active antiretroviral therapy (HAART) [specific drugs and dosages not stated]. The diagnosis of Candida meningitis was not made until postmortem evaluation. The man, who had received HAART several years prior to presentation but was currently not receiving any antiretroviral therapy, initially presented with a bifrontal headache then developed other symptoms including photophobia, meningismus and fevers. His medical history included oral candidiasis, hepatitis C infection, a recent genital herpes infection (treated with valaciclovir) and active intravenous heroin and cocaine use. He was empirically treated with ceftriaxone, ampicillin, vancomycin and aciclovir, and was also empirically treated for herpes simplex virus meningitis, Listeria meningitis and tuberculosis (TB) meningitis. His fever abated, and his photophobia and meningismus resolved. On hospital day 21, HAART was reinitiated, and he was discharged on hospital day 31 receiving his four-drug anti-TB regimen, HAART and prophylactic treatments against Pneumocystis carinii pneumonia and mycobacterium; during hospitalisation, his CD4 count was 20 cells/mm3. After a few days at home, he developed lethargy, weakness and confusion which progressed over 2 weeks. On day 46 from initial presentation, he was rehospitalised. His CD4 count was 12 cells/mm3, but his HIV-1 viral load was less than 400 copies/mL (173 000 copies/mL during initial admission). He was in a worse clinical condition compared with his previous admission. At times, he was difficult to arouse, and had confusion and generalised weakness. A brain MRI showed multiple hyperintensities through the brainstem and thalamus on FLAIR sequences (MRI at initial presentation showed mild periventricular white matter changes). The man became progressively obtunded, and was intubated for tachypnoea and protection of his airways. On day 55, he died. Findings from an autopsy showed a basilar Candida meningitis and vasculitis with CD8+ T-cell infiltration, compatible with IRIS. Author comment: "Thus, our diagnosis in this case was [immune reconstitution syndrome] resulting from initiation of [highly active antiretroviral therapy] in a patient with chronic Candida meningitis." Berkeley JL, et al. Fatal immune reconstitution inflammatory syndrome with human immunodeficiency virus infection and Candida meningitis: case report and review of the literature. Journal of NeuroVirology 14: 267-276, No. 3, May 2008 801111789 USA
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Reactions 5 Jul 2008 No. 1209
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