Study of HIV-positive patients with asymptomatic retroperitoneal lymphadenopathy on antiretroviral therapy for the development of IRIS

Purpose of the study

We conducted an open-labelled prospective observational study of HIV-positive patients on antiretroviral therapy with asymptomatic retroperitoneal lymphadenopathy for the development of Immune Reconstitution Inflammatory Syndrome (IRIS).

Methods

HIV-positive patients attending the Antiretroviral Therapy Centre, at CSM Medical University, Lucknow, India, who were to be initiated on ART according to clinical and immunological criteria, were screened for the presence of asymptomatic abdominal lymphadenopathy by ultrasound. Fifty patients were included in the study. They had no overt evidence of tuberculosis, malignancy, lymphoma, or atypical mycobacterium infection attributable to the enlarged abdominal lymph nodes. Ratio of males to females was 2:1, mean age of presentation was 32.5 yrs and mean CD4 count was 126/cmm. The patients were followed by repeat CD4 count (at 3 months) and clinically (monthly) for the development of IRIS and clinical progression.

Summary of results

Out of 50 patients included in the study, i.e those who were put on ART and had asymptomatic abdominal lymphadenopathy, nine patients (18%) developed signs of IRIS. The mean duration at which patients developed IRIS from the initiation of ART was 33.3 days. One patient developed tubercular meningitis at 2 months, one patient developed vasculitis and infarction in the region of rt. middle cerebral artery presenting as left hemiplegia at 3 months, three patients presented with an increase in the size of the abdominal lymph nodes at approximately one month and four patients presented with persistent fever and generalized lymphadenopathy at approximately 15 days. It was observed that those patients with an initial low CD4 count and good response to ART had a greater incidence of IRIS. The mean CD4 count in patients who developed IRIS was 67/cmm as compared to 215/cmm in those who did not develop IRIS. There was no relation to age, sex and ethnicity of the patient.

Conclusion

We conclude that IRIS is common in Indian HIV-positive patients on ART, particularly those who have low CD4 count. The problem of IRIS may be more significant in Indian patients as they often present late in the course of the disease for ART and the incidence of opportunistic infections is high. There is a need for larger study with longer follow-up on IRIS in Indian HIV patients.