Pulmonary manifestations of the immune reconstitution inflammatory syndrome.

PURPOSE OF REVIEW: Immune reconstitution inflammatory syndrome (IRIS) is a common occurrence in HIV patients starting antiretroviral therapy (ART), and pulmonary involvement is an important feature of tuberculosis-IRIS and pneumocystis-IRIS. Pulmonologists need an awareness of the timing, presentation and treatment of pulmonary IRIS.

RECENT FINDINGS: Case definitions for tuberculosis-IRIS and cryptococcal-IRIS have been published by the International Network for the Study of HIV-associated IRIS (INSHI). A number of studies have addressed validation of clinical case definitions and the optimal time to commence ART after diagnosis of an opportunistic infection in HIV patients. The pathogenesis of IRIS is being assessed at a molecular level, increasing our understanding of mechanisms and possible targets for future preventive and therapeutic strategies.

SUMMARY: Tuberculosis-IRIS, nontuberculosis mycobacterial-IRIS and pneumocystis-IRIS occur within days to weeks of starting ART, causing substantial morbidity, but low mortality. Cryptococcal-IRIS usually occurs later in the course of ART, and may be associated with appreciable mortality. Early recognition of unmasking and paradoxical IRIS affecting the lung allows timely initiation of antimicrobial and/or immunomodulatory therapies.