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Sarcoidosis in Immune Reconstitution Inflammatory Syndrome Complicated by Histoplasmosis and Aspergillosis
Diffuse Lung Disease SESSION TITLE: Sarcoidosis and Cystic Lung Disease SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM
Sarcoidosis in Immune Reconstitution Inflammatory Syndrome Complicated by Histoplasmosis and Aspergillosis Lakshmi Kallur* Sarah Kassaby Dima Youssef and Adel El Abbassi East Tennessee State University, Johnson City, TN INTRODUCTION: Immune reconstitution inflammatory syndrome (IRIS) is a paradoxical worsening of clinical status due to a robust recovery of an immune system in response to highly active antiretroviral therapy (HAART). Numerous responses to IRIS have been recognized in the past including infection, sarcoidosis, autoimmune conditions and tumors. In this article, we review a rare presentation of IRIS manifesting as sarcoidosis. CASE PRESENTATION: A 39-year-old Caucasian male with history of AIDS, diagnosed in 2003, Candida and erosive herpes simplex esophagitis presented to the emergency department. The patient complained of fevers (T ~102 F) and chills, productive cough and shortness of breath for two days. Patient initiated HAART therapy with emtricitabine and tenofovir/ dolutegravir/ darunavir and cobicistat three months ago. On physical exam, rhonchi were auscultated at the right and left lower lung bases. His CD4 count was 10 cells/microL. Computed tomographic (CT) imaging of his chest showed small shotty non specific lymph nodes in the upper mediastinum with deposits throughout the upper lobes bilaterally extending down with less concentration in the mid and lower portion of the chest. A bronchoscopy was performed and specimens were obtained which revealed noncaseating granulomatous inflammation among bronchial and alveolar tissue (Fig A&B). Patient was empirically started on intravenous anidulafungin, valgancyclovir, azithromycin, ceftriaxone and atovaquone. Subsequently, the patient was found to have positive urinary antigen for Histoplasmosis and serum aspergillus antigen. Patient was discharged with itraconazole, valgancylcovir and atovaquone
CONCLUSIONS: This case emphasizes the rare occurence of sarcoidosis during the robust recovery phase of IRIS in a HIV T cell depleted state. Reference #1: Trevenzoli, M., Cattelan, A. M., Marino, F., Marchioro, U., & Cadrobbi, P. (2003). Sarcoidosis and HIV infection: A case report and a review of the literature. Postgraduate Medical Journal, 79(935), 535. DISCLOSURE: The following authors have nothing to disclose: Lakshmi Kallur, Sarah Kassaby, Dima Youssef, Adel El Abbassi No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2017.08.508
Copyright ª 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
chestjournal.org
481A
DIFFUSE LUNG DISEASE
DISCUSSION: The underlying mechanism of sarcoidosis includes the recruitment of alveolar macrophages, T lymphocytes, regulatory T cells, and various cytokines/ chemokines in organizing a sarcoid granulomatous lesion. Although theoretically HIV is a T cell depleted state, sarcoidosis has been reported in various reports in response to IRIS. According to a study performed by Morris et al, granulomatous inflammation of sarcoidosis has been recorded in HIV patients where in most cases, the CD4+ cell count exceeded 200 cells/ microL. Sarcoidosis appears to be a manifestation of disease related to restoration of immune system. HAART therapy appears to dysregulate immune response components such as Th1-type CD4 cells secreting IL-2 and interferon gamma, leading to granuloma formation. According to Haramati et al, there were no radiographic differences in sarcoidosis found in HIV infected versus HIV non infected patients.
Sarcoidosis in Immune Reconstitution Inflammatory Syndrome Complicated by Histoplasmosis and Aspergillosis Lakshmi Kallur* Sarah Kassaby Dima Youssef and Adel El Abbassi East Tennessee State University, Johnson City, TN INTRODUCTION: Immune reconstitution inflammatory syndrome (IRIS) is a paradoxical worsening of clinical status due to a robust recovery of an immune system in response to highly active antiretroviral therapy (HAART). Numerous responses to IRIS have been recognized in the past including infection, sarcoidosis, autoimmune conditions and tumors. In this article, we review a rare presentation of IRIS manifesting as sarcoidosis. CASE PRESENTATION: A 39-year-old Caucasian male with history of AIDS, diagnosed in 2003, Candida and erosive herpes simplex esophagitis presented to the emergency department. The patient complained of fevers (T ~102 F) and chills, productive cough and shortness of breath for two days. Patient initiated HAART therapy with emtricitabine and tenofovir/ dolutegravir/ darunavir and cobicistat three months ago. On physical exam, rhonchi were auscultated at the right and left lower lung bases. His CD4 count was 10 cells/microL. Computed tomographic (CT) imaging of his chest showed small shotty non specific lymph nodes in the upper mediastinum with deposits throughout the upper lobes bilaterally extending down with less concentration in the mid and lower portion of the chest. A bronchoscopy was performed and specimens were obtained which revealed noncaseating granulomatous inflammation among bronchial and alveolar tissue (Fig A&B). Patient was empirically started on intravenous anidulafungin, valgancyclovir, azithromycin, ceftriaxone and atovaquone. Subsequently, the patient was found to have positive urinary antigen for Histoplasmosis and serum aspergillus antigen. Patient was discharged with itraconazole, valgancylcovir and atovaquone
CONCLUSIONS: This case emphasizes the rare occurence of sarcoidosis during the robust recovery phase of IRIS in a HIV T cell depleted state. Reference #1: Trevenzoli, M., Cattelan, A. M., Marino, F., Marchioro, U., & Cadrobbi, P. (2003). Sarcoidosis and HIV infection: A case report and a review of the literature. Postgraduate Medical Journal, 79(935), 535. DISCLOSURE: The following authors have nothing to disclose: Lakshmi Kallur, Sarah Kassaby, Dima Youssef, Adel El Abbassi No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2017.08.508
Copyright ª 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
chestjournal.org
481A
DIFFUSE LUNG DISEASE
DISCUSSION: The underlying mechanism of sarcoidosis includes the recruitment of alveolar macrophages, T lymphocytes, regulatory T cells, and various cytokines/ chemokines in organizing a sarcoid granulomatous lesion. Although theoretically HIV is a T cell depleted state, sarcoidosis has been reported in various reports in response to IRIS. According to a study performed by Morris et al, granulomatous inflammation of sarcoidosis has been recorded in HIV patients where in most cases, the CD4+ cell count exceeded 200 cells/ microL. Sarcoidosis appears to be a manifestation of disease related to restoration of immune system. HAART therapy appears to dysregulate immune response components such as Th1-type CD4 cells secreting IL-2 and interferon gamma, leading to granuloma formation. According to Haramati et al, there were no radiographic differences in sarcoidosis found in HIV infected versus HIV non infected patients.