Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe cutaneous adverse reaction involving various internal organs. Flare-ups after recovery from the initial presentation of DRESS are caused by relapse of drug-induced T-cell-mediated reactions. However, the specific underlying mechanism is unclear. Here, we report a case of a 60-year-old man with allopurinol-induced DRESS who suffered recurrent episodes of generalized rash with eosinophilia, which mimicked immune reconstitution inflammatory syndrome. Analysis of immunological profiles revealed that the percentages of T lymphocytes and regulatory T cells in the patient with DRESS were higher than those in healthy controls. In addition, there was a notable change in the subtype of monocytes in the patient with DRESS; the percentage of nonclassical monocytes increased, whereas that of classical monocytes decreased. Upon viral infection, nonclassical monocytes exhibited strong pro-inflammatory properties that skewed the immune response toward a Th2 profile, which was associated with persistent flare-ups of DRESS. Taken together, the results increase our understanding of the pathogenesis of DRESS as they suggest that expansion of nonclassical monocytes and Th2 cells drives disease pathogenesis.
Allopurinol ; Drug Hypersensitivity Syndrome ; Eosinophilia ; Exanthema ; Herpesviridae ; Humans ; Immune Reconstitution Inflammatory Syndrome ; Middle Aged ; Monocytes ; Recurrence ; T-Lymphocytes ; T-Lymphocytes, Regulatory ; Th2 Cells

In acquired immunodeficiency syndrome (AIDS) patients, immune reconstitution inflammatory syndrome (IRIS) due to Mycobacterium avium complex (MAC) infection is one of the most difficult IRIS types to manage. We report an unusual case of MAC-associated IRIS. At first the patient was diagnosed human immunodeficiency virus (HIV) infection after he was admitted with pneumocystis pneumonia. After starting antiretroviral therapy he presented unmasked IRIS with MAC infection. Next, he was hospitalized with continuous loose stools and new-onset fever. Investigation included computed tomography (CT), which showed homogeneous enhancement and enlargement of the lymph nodes (LN), elevation of ferritin (>1,650 ng/mL) and lactate dehydrogenase (306 IU/L) levels, and F- fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) scan, which showed increased FDG uptake. These findings were highly indicative of lymphoma. We performed laparoscopic biopsy of the mesenteric LN, and the biopsy culture grew MAC. So we made a diagnosis of MAC-associated. Therefore, IRIS must be considered as a possible diagnosis when AIDS patients develop new symptoms or exhibit exacerbations of existing symptoms. Furthermore the biopsies should be conducted.
Acquired Immunodeficiency Syndrome ; Biopsy ; Diagnosis ; Electrons ; Ferritins ; Fever ; HIV ; Humans* ; Immune Reconstitution Inflammatory Syndrome* ; Iris ; L-Lactate Dehydrogenase ; Lymph Nodes ; Lymphoma* ; Mycobacterium avium Complex* ; Mycobacterium avium* ; Mycobacterium* ; Pneumonia, Pneumocystis

In acquired immunodeficiency syndrome (AIDS) patients, immune reconstitution inflammatory syndrome (IRIS) due to Mycobacterium avium complex (MAC) infection is one of the most difficult IRIS types to manage. We report an unusual case of MAC-associated IRIS. At first the patient was diagnosed human immunodeficiency virus (HIV) infection after he was admitted with pneumocystis pneumonia. After starting antiretroviral therapy he presented unmasked IRIS with MAC infection. Next, he was hospitalized with continuous loose stools and new-onset fever. Investigation included computed tomography (CT), which showed homogeneous enhancement and enlargement of the lymph nodes (LN), elevation of ferritin (>1,650 ng/mL) and lactate dehydrogenase (306 IU/L) levels, and F- fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) scan, which showed increased FDG uptake. These findings were highly indicative of lymphoma. We performed laparoscopic biopsy of the mesenteric LN, and the biopsy culture grew MAC. So we made a diagnosis of MAC-associated. Therefore, IRIS must be considered as a possible diagnosis when AIDS patients develop new symptoms or exhibit exacerbations of existing symptoms. Furthermore the biopsies should be conducted.
Acquired Immunodeficiency Syndrome ; Biopsy ; Diagnosis ; Electrons ; Ferritins ; Fever ; HIV ; Humans* ; Immune Reconstitution Inflammatory Syndrome* ; Iris ; L-Lactate Dehydrogenase ; Lymph Nodes ; Lymphoma* ; Mycobacterium avium Complex* ; Mycobacterium avium* ; Mycobacterium* ; Pneumonia, Pneumocystis

Invasive aspergillosis (IA) is one of the most common life-threatening complications in immunocompromised patients. Voriconazole is currently the drug of choice for IA treatment. However, some patients with IA suffer clinical deterioration despite voriconazole therapy. Management of voriconazole-refractory IA remains challenging; no useful recommendations have yet been made. Voriconazole-refractory IA can be further categorized as disease attributable to misdiagnosis or co-infection with another mold; inadequate blood voriconazole blood; inadequate tissue drug concentrations attributable to angioinvasion; immune reconstitution inflammatory syndrome; or infection with voriconazole-resistant Aspergillus. Hence, when encountering a case of voriconazole-refractory IA, it is necessary to schedule sequential tests to decide whether medical treatment or surgical intervention is appropriate; to adjust the voriconazole dose via drug monitoring; to seek CYp2c19 polymorphisms; to monitor serum galactomannan levels; and to examine the drug susceptibility of the causative Aspergillus species.
Appointments and Schedules ; Aspergillosis* ; Aspergillus ; Coinfection ; Cytochrome P-450 CYP2C19 ; Diagnostic Errors ; Drug Monitoring ; Fungi ; Humans ; Immune Reconstitution Inflammatory Syndrome ; Immunocompromised Host ; Voriconazole

Tuberculosis is one of the most common opportunistic diseases in human immunodeficiency virus (HIV)-infected patients in Korea, and extra-pulmonary infections are frequent in these patients. Cutaneous miliary tuberculosis is a rare form of tuberculosis that presents as a papulopustular eruption and hematogenous dissemination of Mycobacterium tuberculosis to multiple organs. This has been reported in patients with progressive HIV infection. We report the first case of cutaneous miliary tuberculosis that developed as a manifestation of immune reconstitution inflammatory syndrome (IRIS) after initiating antiretroviral therapy (ART).
HIV ; HIV Infections ; Humans ; Immune Reconstitution Inflammatory Syndrome* ; Korea ; Mycobacterium tuberculosis ; Skin ; Tuberculosis ; Tuberculosis, Miliary*

PURPOSE: Lymphocyte subset recovery is an important factor that determines the success of hematopoietic stem cell transplantation (HSCT). Temporal differences in the recovery of lymphocyte subsets and the factors influencing this recovery are important variables that affect a patient's post-transplant immune reconstitution, and therefore require investigation. METHODS: The time taken to achieve lymphocyte subset recovery and the factors influencing this recovery were investigated in 59 children who had undergone HSCT at the Department of Pediatrics, The Catholic University of Korea Seoul St. Mary's Hospital, and who had an uneventful follow-up period of at least 1 year. Analyses were carried out at 3 and 12 months post-transplant. An additional study was performed 1 month post-transplant to evaluate natural killer (NK) cell recovery. The impact of pre- and post-transplant variables, including diagnosis of Epstein-Barr virus (EBV) DNAemia posttransplant, on lymphocyte recovery was evaluated. RESULTS: The lymphocyte subsets recovered in the following order: NK cells, cytotoxic T cells, B cells, and helper T cells. At 1 month post-transplant, acute graft-versus-host disease was found to contribute significantly to the delay of CD16+/56+ cell recovery. Younger patients showed delayed recovery of both CD3+/CD8+ and CD19+ cells. EBV DNAemia had a deleterious impact on the recovery of both CD3+ and CD3+/CD4+ lymphocytes at 1 year post-transplant. CONCLUSION: In our pediatric allogeneic HSCT cohort, helper T cells were the last subset to recover. Younger age and EBV DNAemia had a negative impact on the post-transplant recovery of T cells and B cells.
B-Lymphocytes ; Child ; Cohort Studies ; Follow-Up Studies ; Graft vs Host Disease ; Hematopoietic Stem Cell Transplantation ; Hematopoietic Stem Cells ; Herpesvirus 4, Human ; Humans ; Immune Reconstitution Inflammatory Syndrome ; Killer Cells, Natural ; Korea ; Lymphocyte Subsets ; Lymphocytes ; Pediatrics ; T-Lymphocytes ; T-Lymphocytes, Helper-Inducer

Highly active antiretroviral therapy (HAART), which restores specific immune responses, may paradoxically cause an inflammatory reaction known as immune reconstitution inflammatory syndrome (IRIS). We report a patient with acquired immune deficiency syndrome, who presented Molluscum contagiosum as IRIS after HAART, the first case in Korea.
Acquired Immunodeficiency Syndrome ; Antiretroviral Therapy, Highly Active ; HIV ; Humans ; Immune Reconstitution Inflammatory Syndrome ; Iris ; Korea ; Molluscum Contagiosum ; Skin ; Skin Manifestations

Adult ; Aged ; Antimalarials ; therapeutic use ; Female ; Humans ; Immune Reconstitution Inflammatory Syndrome ; drug therapy ; JC Virus ; immunology ; Leukoencephalopathy, Progressive Multifocal ; drug therapy ; Male ; Mefloquine ; therapeutic use ; Middle Aged ; Treatment Outcome

According to current evidence, human immunodeficiency virus (HIV)-infected patients who have undergone treatment with antiretroviral therapy are at greater risk of developing herpes zoster, not when they are severely immunocompromised, but, paradoxically, when their immune system is recovering. This is a manifestation of the immune reconstitution inflammatory syndrome (IRIS). Here we report on a case of IRIS, presented as herpes zoster in a HIV-infected patient after undergoing highly active antiretroviral therapy (HAART).
Antiretroviral Therapy, Highly Active ; Herpes Zoster ; HIV ; Humans ; Immune Reconstitution Inflammatory Syndrome ; Immune System ; Iris

Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system due to JC virus. In acquired immunodeficiency syndrome (AIDS) patients, JC virus infects myelin-producing oligodendrocytes causing a non-inflammatory lytic reaction leading to demyelination and brain death. We herein report a case of a 56-years-old AIDS man who developed immune reconstitution inflammatory syndrome and died while undergoing highly active antiretroviral therapy. In this patient, the PML involved the brainstem, causing mental confusion followed by recurrent aspiration, adult respiratory distress syndrome, and eventually to early death.
Acquired Immunodeficiency Syndrome ; Antiretroviral Therapy, Highly Active ; Brain Death ; Brain Stem ; Central Nervous System ; Demyelinating Diseases ; Humans ; Immune Reconstitution Inflammatory Syndrome ; JC Virus ; Leukoencephalopathy, Progressive Multifocal ; Oligodendroglia ; Respiratory Distress Syndrome, Adult