Questions and Answers with NAM Keith Alcorn, senior editor, NAM
I recently started treatment because my CD4 count fell very low and
I was very ill. Now I am getting fevers and have a swelling in my neck. My
doctor says I shouldn’t worry and that it’s a sign my immune system
is getting better; she calls it an immune restoration syndrome. I thought
the drugs were meant to make me better, not make me sick again?
An immune restoration illness is not a sign your treatment is failing, in
fact, it’s a sign of success. Sometimes the immune system reacts in
this way. During the powerful boost to the immune system that happens in the
first months of antiretroviral treatment, a strong reaction may occur to underlying
infections or remnants of past infections. Most commonly, people experience
flare-ups of underlying herpes infections, resulting in genital herpes or
shingles. These occur because the immune system rapidly regains the ability
to respond strongly to these viruses. Flare-ups of genital warts appear to
be frequent too.
What about the fevers and swelling?
What you are specifically describing sounds like an immune restoration illness
linked to previous exposure to tuberculosis (TB). The immune system is reacting,
not to active, infectious TB, but to non-infectious
fragments of the bacteria that cause TB.
The immune system goes into overdrive, and TB-like symptoms such as fevers
and swollen lymph nodes in the neck, armpits and groin can emerge. This syndrome
is sometimes called IRIS, immune reconstitution inflammatory syndrome. Up
to a third of people with previous exposure to TB may develop this syndrome,
and it’s most likely to happen if you start HIV treatment less than
six to eight weeks after starting TB treatment. This is one reason why doctors
try to avoid starting the two treatments at the same time.
How can the syndrome be treated?
In the case of a TB reaction, these symptoms should go away, but some people
may need to have the swollen lymph nodes drained to make them return to their
normal size.
Rarely, people develop inflammation at the back of the eye as a result of
immune reactions to cytomegalovirus (CMV). These are the most dangerous immune
restoration disorders and may need to be treated with steroids. In the case
of herpes, shingles, genital warts or other skin conditions caused by viruses,
the usual treatment will be given.
Shouldn’t my doctor have predicted this would happen?
The only thing that seems to predict a higher risk of developing an immune
restoration
illness is starting treatment with a CD4 count below 100. A past history of
an illness does not mean you will automatically get a recurrence of the symptoms,
unless you have previously suffered from genital herpes or genital warts.
In the case of TB IRIS, your doctor may be unable to spot that you have prior
exposure to TB because in people with very advanced HIV and very low CD4 cell
count, the skin test used to check for prior TB exposure may show no reaction.
This is because the part of the immune system which should ‘remember’
how to respond to TB is so depleted, the body mounts no reaction. For more
details on TB see feature TB Almost Killed Me, pg 30.
There is probably a genetic basis to who gets immune restoration syndromes,
especially those related to herpes viruses, but as yet there are no genetic
tests that can predict what might happen to an individual.
• NAM provides information to help you think about your use of HIV treatments,
but this is not intended to replace discussion with your doctor.
