Characterization of immune reconstitution inflammatory syndrome in a cohort in a Mexican cohort
Main Article Content
Keywords
HIV, Immune Reconstitution Inflammatory Syndrome, Opportunistic Infections, Anti-Retroviral Agents
Abstract
Abstract
Background: Immune reconstitution inflammatory syndrome (IRIS) is an exaggerated inflammatory response to previously acquired opportunistic pathogens, causing clinical deterioration in the first months after starting antiretroviral therapy, contributing to morbidity and mortality in people living with HIV (PLHIV). In Mexico, data are limited, but IRIS has been reported in 11.4 - 27% of patients, with Varicella zoster as the most frequently associated pathogen and a mortality rate of 4.9 deaths per 100 person-years.
Objective: To describe clinical and etiological characteristics of immune reconstitution inflammatory syndrome in patients treated at a tertiary care hospital in Mexico.
Material and methods: A cross-sectional, retrospective study, through the review of medical records from the Hospital de Especialidades CMN Siglo XXI, including patients with recent HIV diagnosis between January 1, 2017, and June 31, 2023. Variables were recorded and analyzed using SPSS v.25, with p < 0.05 considered statistically significant.
Results: 55 patients were included; 45 (81.8%) presented unmasking IRIS, with a median onset time of 6 (4–12) weeks after starting ART. M. tuberculosis was the most frequent pathogen (27.3%). There were eight deaths (14.5%), due to pneumocystis pneumonia and cerebral toxoplasmosis. Corticosteroid use was associated with higher mortality.
Conclusions: The most frequent pathogens associated with IRIS were M. tuberculosis and cytomegalovirus. The case-fatality rate was 14.5%, higher than that reported in other Mexican series.
References
1. Nachega JB, Musoke P, Kilmarx PH, et al. Global HIV control: is the glass half empty or half full? Lancet HIV. 2023;10(9):e617–22. Available from: http:dx.doi.org/10.1016/S2352-3018(23)00150-9
2. Vinhaes CL, Araujo-Pereira M, Tibúrcio R, et al. Systemic inflammation associated with immune reconstitution inflammatory syndrome in persons living with HIV. Life (Basel). 2021;11(1):65. Available from: http://dx.doi.org/10.3390/life11010065
3. Thapa S, Shrestha U. Immune reconstitution inflammatory syndrome. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2025.
4. Kohli A, Tajik S, Abdulfattah O. Immune reconstitution syndrome caused by nontuberculous mycobacteria: A case report and review of literature. Cureus. 2024;16(7):e64146. Available from: http://dx.doi.org/10.7759/cureus.64146
5. Geteneh A, Andualem H, Belay DM, et al. Immune reconstitution inflammatory syndrome, a controversial burden in the East African context: a systematic review and meta-analysis. Front Med (Lausanne). 2023;10:1192086. Available from: http://dx.doi.org/10.3389/fmed.2023.1192086
6. Richards GA, Zamparini J, Kalla I, et al. Critical illness due to infection in people living with HIV. Lancet HIV. 2024;11(6):e406–18. Available from: http://dx.doi.org/10.1016/S2352-3018(24)00096-1
7. Schregenberger S, Graup V, Schibli A, et al. Immune reconstitution inflammatory syndrome (IRIS): Case series and review of the literature. Respir Med Case Rep. 2025;55(102213):102213. Available from: http://dx.doi.org/10.1016/j.rmcr.2025.102213
8. French MA. The immunopathogenesis of immune reconstitution inflammatory syndrome has become clearer, but more complex. J Infect Dis. 2023;228(2):106–10. Available from: http://dx.doi.org/10.1093/infdis/jiad100
9. Avila-García M, Figueroa-Damián R. Síndrome inflamatorio de reconstitución inmunológica (SIR S) en la salud reproductiva. Rev Perinat Reprod Hum. 2024;37(3):122–9. Available from: https://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0187-5337202300030012
10. Xue M, Xie R, Pang Y, et al. Prevalence and risk factors of paradoxical tuberculosis associated immune reconstitution inflammatory syndrome among HIV-infected patients in Beijing, China. BMC Infect Dis. 2020;20(1):554. Available from: http://dx.doi.org/10.1186/s12879-020-05225-x
11. Silveira-Mattos PS, Narendran G, Akrami K, et al. Differential expression of CXCR3 and CCR6 on CD4+ T-lymphocytes with distinct memory phenotypes characterizes tuberculosis-associated immune reconstitution inflammatory syndrome. Sci Rep. 2019;9(1):1502. Available from: http://dx.doi.org/10.1038/s41598-018-37846-3
12. de Sá NBR, de Souza NCS, Neira-Goulart M, et al. Inflammasome genetic variants are associated with tuberculosis, HIV-1 infection, and TB/HIV-immune reconstitution inflammatory syndrome outcomes. Front Cell Infect Microbiol. 2022;12:962059. Available from: http://dx.doi.org/10.3389/fcimb.2022.962059
13. Vinhaes CL, Sheikh V, Oliveira-de-Souza D, et al. An inflammatory composite score predicts Mycobacterial immune reconstitution inflammatory syndrome in people with advanced HIV: A prospective international cohort study. J Infect Dis. 2021;223(7):1275–83. Available from: http://dx.doi.org/10.1093/infdis/jiaa484
14. Brust JCM, McGowan JP, Fine SM, et al. Management of IRIS. Baltimore (MD): Johns Hopkins University; 2024.
15. Hammond CK, Kanzie P, Martyn-Dickens C, et al. AIDS virus. Semin Pediatr Neurol. 2025;54(101205):101205. Available from: http://dx.doi.org/10.1016/j.spen.2025.101205
16. Hoyo-Ulloa I, Belaunzarán-Zamudio PF, Crabtree-Ramirez B, et al. Impact of the immune reconstitution inflammatory syndrome (IRIS) on mortality and morbidity in HIV-infected patients in Mexico. Int J Infect Dis. 2011;15(6):e408-14. Available from: http://dx.doi.org/10.1016/j.ijid.2011.02.007
17. Castillejos-García I, Ramírez-Amador V, Gómez-Mejía E, et al. Clinical manifestations and risk factors for oral immune reconstitution inflammatory syndrome in Mexico. Oral Dis. 2020;26 Suppl 1(S1):153–7. Available from: http://dx.doi.org/10.1111/odi.13402
18. Ceballos-Liceaga SE, Soledad-Mendoza ME, Carbajal-Sandoval G, et al. Sistema de vigilancia epidemiológica de VIH. Gob.mx. 2024 [cited 2024 Jan 22]. Available from: https://www.gob.mx/cms/uploads/attachment/file/872352/VIH_DVEET_3erTrim_2023.pdf
19. Novelli S, Delobel P, Bouchaud O, et al. Enhanced immunovirological response in women compared to men after antiretroviral therapy initiation during acute and early HIV-1 infection: results from a longitudinal study in the French ANRS Primo cohort. J Int AIDS Soc. 2020;23(4):e25485. Available from: http://dx.doi.org/10.1002/jia2.25485
20. Sereti I, Sheikh V, Shaffer D, et al. Prospective international study of incidence and predictors of immune reconstitution inflammatory syndrome and death in people living with human immunodeficiency virus and severe lymphopenia. Clin Infect Dis. 2020;71(3):652–60. Available from: http://dx.doi.org/10.1093/cid/ciz877
21. Rocco JM, Laidlaw E, Galindo F, et al. Severe Mycobacterial immune reconstitution inflammatory syndrome (IRIS) in advanced human immunodeficiency virus (HIV) has features of hemophagocytic lymphohistiocytosis and requires prolonged immune suppression. Clin Infect Dis. 2023;76(3):e561–70. Available from: http://dx.doi.org/10.1093/cid/ciac717
22. Lyu W, Cai W, Chen Y, et al. Expert consensus on the clinical management of HIV late presentation. Infect Dis Immun. 2025; Available from: http://dx.doi.org/10.1097/id9.0000000000000182
23. Geneva: World Health Organization. Consolidated Guidelines on HIV Prevention, Testing, Treatment, Service Delivery and Monitoring: Recommendations for a Public Health Approach. 2021. Available from: https://www-ncbi-nlm-nih-gov.pbidi.unam.mx:2443/books/NBK572730/
24. Zhao Y, Hohlfeld A, Namale P, et al. Risk of immune reconstitution inflammatory syndrome with integrase inhibitors versus other classes of antiretrovirals: A systematic review and meta-analysis of randomized trials. J Acquir Immune Defic Syndr. 2022;90(2):232–9. Available from: http://dx.doi.org/10.1097/QAI.0000000000002937
25. Chan CK, Huang SS, Wong KH, et al. No increased risk of tuberculosis-related immune reconstitution inflammatory syndrome with integrase inhibitor-based antiretroviral therapy in people with HIV with profound immunosuppression. HIV Med. 2024;25(11):1270–6. Available from: http://dx.doi.org/10.1111/hiv.13695
26. Martínez-Bravo LE, Hidalgo-Díaz DA, Téllez-Marroquín R. Unmasking tuberculosis - Immune reconstitution inflammatory syndrome manifested as meningitis. Medical Reports. 2025;12(100214):100214. Available from: http://dx.doi.org/10.1016/j.hmedic.2025.100214
27. Gurcuoglu E, Tuna B, Ortac H, Gursoy V. IRIS and mortality in advanced HIV: Post-pandemic experience from a single-center case series. Research Square. 2025. Available from: http://dx.doi.org/10.21203/rs.3.rs-7742557/v1
28. Chauvin M, Sauce D. Mechanisms of immune aging in HIV. Clin Sci (Lond). 2022;136(1):61–80. Available from: http://dx.doi.org/10.1042/CS20210344
29. Walker NF, Scriven J, Meintjes G, et al. Immune reconstitution inflammatory syndrome in HIV-infected patients. HIV AIDS (Auckl). 2015;7:49–64. Available from: http://dx.doi.org/10.2147/HIV.S42328
30. Spinner CD, Barton J, Biever P, et al. Steroids in infection medicine. Dtsch Med Wochenschr. 2021;146(3):162–6. Available from: http://dx.doi.org/10.1055/a-1302-3530
Article Sidebar
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
Authors retain their copyright and grant the Revista Médica del IMSS the right of first publication. Articles are distributed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which allows sharing as long as the author and the original source are properly credited.