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ARTICLES: J. A. McCombe, R. N. Auer, F. G. Maingat, S. Houston, M. J. Gill, and C. Power Neurologic immune reconstitution inflammatory syndrome in HIV/AIDS: Outcome and epidemiology Neurology 2009; 72: 835-841 [Abstract] [Full text] [PDF]

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Neurologic immune reconstitution inflammatory syndrome in HIV/AIDS: Outcome and epidemiology

Subsai Kongsaengdao, Bangkok 10400 Thailand   (10 April 2009)

Reply from the authors

Christopher Power, Jennifer McCombe   (10 April 2009)

Neurologic immune reconstitution inflammatory syndrome in HIV/AIDS: Outcome and epidemiology 10 April 2009
Subsai Kongsaengdao, Rajavithi Hospital 2 Rajavithi Hospital (VictoryMonument), Bangkok 10400 Thailand Send Correspondence to journal: Re: Neurologic immune reconstitution inflammatory syndrome in HIV/AIDS: Outcome and epidemiology skhongsa{at}gmail.com Subsai Kongsaengdao, et al.	In their article, McCombe et al. [1] refer to our AIDS study. [2] The authors stated: “If one combined the two groups included in the Thai study, this would be an overestimate of the incidence as the investigators included complications such as ischemic and hemorrhagic stroke in this group, which does not represent the effects of an inflammatory response in the context of a recovering immune system.” The ischemic and hemorrhagic strokes counted in the NeuroIRIS incidence were from the inflammatory process. All ischemic strokes in our study resulted from secondary CNS vasculitis and herpes zoster vasculitis after initiation of HAART. In addition, hemorrhagic strokes resulted from secondary toxoplasmic abscess with bleeding after initiation of HAART, which had inflammation at the abscess wall indicated by CT and MRI in the figure. The incidence was not overestimated. Reference 1. 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;72:835-841. 2. Subsai K, Kanoksri S, Siwaporn C, et al. Neurological complication in AIDS patients receiving HAART: a 2-year retrospective study. Eur J Neurol 2006;13:233–239 Disclosure: The author reports no disclosures.
Reply from the authors 10 April 2009
Christopher Power, University of Alberta 6-11 HMRC, University of Alberta, Edmonton AB T6G 2S2, Jennifer McCombe Send Correspondence to journal: Re: Reply from the authors chris.power{at}ualberta.ca Christopher Power, et al.	We thank Dr. Kongsaengdao for the timely response. Our report described the clinical features and incidence (0.9%) of neurologic immune reconstitution inflammatory syndrome (NeuroIRIS) occurring among HIV/AIDS patients in whom combination antiretroviral therapy (cART) was initiated in Alberta, Canada. [1] Kongsaengdao et al. also reported the incidence of neurological complications occurring in their patient population after the initiation of cART. [2] As our studies were similar in their intent, we contrasted our results with those of Dr. Kongsaengdao et al.’s but given the differences in our respective definitions of NeuroIRIS, it is not valid to make a direct comparison. The key difference lies in the interval leading to neurologic deterioration. Kongsaengdao et al.’s cohort included only those patients who had been on cART for at least one month. In contrast, four of our seven patients presented within four weeks of the initiation of cART, which underscores the differences in the two cohorts. The diagnoses included in the Kongsaengdao et al. cohort also differed markedly from our cohort: six of the patients included in the non-NIRIS group in the Kongsaengdao et al. report presented with hemorrhagic or ischemic stroke. One of the hemorrhages accompanied a toxoplasmic abscess and the other was an aneurysmal-related hemorrhage. The remaining four cases were of ischemic stroke: three large vessel and one lacunar infarction. The aneurysmal hemorrhage and the four ischemic events may not have represented the effects of an inflammatory response in the context of a recovering immune system. Dr. Kongsaengdao mentions that the ischemic strokes were all secondary to vasculitis. Vasculitis is described in HIV infection [3] and several reports have highlighted cases of neurological deterioration shortly after initiating cART, with a subsequent diagnosis of CNS vasculitis. [4,5] The cases described by Melica et al. had multiple ischemic lesions typical of a diagnosis of CNS vasculitis. [6] The case reported by Chang et al. described pathologically confirmed necrotizing vasculitis involving the length of the spinal cord. Although we lack the details of the cases reported by Kongsaengdao et al., a single lacular infarct would be an atypical presentation for CNS vasculitis. In addition to vasculitis, other causes of stroke include the metabolic syndrome attributed to specific antiretroviral drugs, potential hematological abnormalities, in addition to other confounding variables including illicit drug use and tobacco smoking. References 2. Subsai K, Kanoksri S, Siwaporn C, Helen L, Kanoporn O, Wantana P. Neurological complications in AIDS patients receiving HAART: A 2 year retrospective study. Eur J Neurol 2006;13:233-239. 3. Guillevin L. Vasculitides in the context of HIV infection. AIDS 2008;22(suppl 3):S27–S33. 4. Melica G, Brugieres P, Lascaux AS, Levy Y, Lelièvre JD. Primary vasculitis of the central nervous system in patients infected with HIV-1 in the HAART era. J Med Virol 2009;81:578-581. 5. Chang CC, McLean C, Vujovic O et al. Fatal acute varicella-zoster virus hemorrhagic meningomyelitis with necrotizing vasculitis in an HIV-infected patient. Clin Infect Dis 2009;48:372-373. 6. Küker W. Imaging of cerebral vasculitis. International Journal of Stroke 2007;2:184-190. Disclosure: The authors report no disclosures.