The Tragedies of IRIS

In the complete absence of anything interesting happening in the Musculo-module, I have decided to write up an interesting case we had during our time in the Paediatric Infections ward. Please note that, as always, I write this as a student and thus my work is bound to have flaws. There will be an absence of good medical terminology or pharmaceutical “correctness”. If that will bother you, you’d best not read it.

As every layman knows, the Human Immunodeficiency Virus has as its prime target CD4 cells, which has adverse effects on the immune system. In general it suppresses immunity up to the point where various opportunistic infections find their way through a hole-y firewall. This is what usually causes death in HIV-infected patients.

Sometimes, however, the immune system is affected in such a way that it simply does not recognise certain pathogens. Some infections cause damage to the body not necessarily by the actual bug, but by the body’s response to its presence. TB is a very good example of this – Mycoplasma Tuberculosis bacilli are quite placid little things.

In other words, untreated HIV-patients often harbour some opportunistic, but sub-clinical, infections.

What often happens – and what we saw in the Infectious Ward – is that a child is diagnosed with HIV and is started onhighly active antiretroviral therapy (HAART); and suddenly his CD4-count soars and all these subclinical infections are unmasked – effectively releasing a battalion of assaults on the child’s body.

This is called Immune Reconstitution Inflammatory Syndrome – IRIS.

A lot of the patients we had may or may not have been experiencing IRIS – ones with Pneumocystis JiroveciiPneumonia or chronic diarrhoeas. Two patients however had very specific IRIS pictures.

One was an eight-month-old (the one previously referred to as “the Petri Dish”) with Cytomegalovirus (CMV). The CMV manifested in a very rare manner, namely CMV-retinitis. When we first arrived in the ward, he had severe strabismus, but it was evident that he could see. Two weeks later we had to examine the same patient for a tutorial on neurology. His eyes were roaming and there was no pupillary response to light. The registrar told us that the patient was now clinically blind.

The other patient was a little boy about ten years of age (I am not sure; it could have been a little less). When we met him he looked healthy and active and we wondered what had brought him here.

As it turns out, he had presented to his local clinic with signs of pulmonary TB. He was then also diagnosed with HIV and started on HAART. A few days later he started having seizures and was sent to the hospital with several cerebellar signs.

MRIs revealed a large Tuberculoma in one cerebral hemisphere – the IRIS-picture. Neurosurgeons deemed it too large to excise. The HAART had to be stopped, he was placed on large doses of corticosteroids and was soon back to (what appeared to be) normal.

They tried a second time to restart HAART and the same thing happened. Maybe not quite the same – perhaps a little worse.

On our last day in this ward, a Friday, my attention stayed a little and I was brought back to Earth by the consultant asking, “Who do you side with?” My bewildered response eventually lead to the explanation that she was enquiring as to my religion. She then said, “Good, now we need a Jew.” Turning to the registrar, “Are you Jewish? Why not?!”

It finally dawned that she was – albeit jokingly – organising a prayer group for that Monday, when the patient’s HAART would be restarted once more. By now he had been placed on a drug that is usually used for transplant patients. I am still not sure how ARVs would still work this way, but anyway.

A week and a half later we were back in the ward for a tutorial. We saw the young boy, but did not have the opportunity to read his file. I do hope that the ARVs worked this time. It is too sad how many children suffer HIV and its many complications for deeds they never committed, nor condoned.

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