Immune Reconstitution Inflammatory Syndrome (IRIS)
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Please click on the link below to access the most up-to-date version of this guideline. The content on this page is currently being updated to align with the latest publication. Always check the version number at the bottom of the screen to confirm which version you are using.
Description
General measures
Medicine treatment
D89.3 + (Y41.5 + B24)
DESCRIPTION
IRIS occurs when improving immune function unmasks a previously occult opportunistic disease (“unmasking IRIS”), or causes paradoxical deterioration of an existing opportunistic disease (“paradoxical IRIS”). IRIS is more common in patients with advanced HIV disease, particularly those with a CD4 count <100 cells/mm3 . IRIS nearly always presents during the first 3 months of ART, with the median time of onset being about two weeks. The diagnosis of paradoxical IRIS is often difficult as new opportunistic diseases, or drug resistance of the organism causing the opportunistic infection, need to be excluded.
TB is the commonest opportunistic disease involved in IRIS reactions in South Africa. Paradoxical TB IRIS presents as recurrence or worsening of TB symptoms/signs, or new manifestations. The commonest presentation is with enlarging lymph nodes, often with extensive caseous necrosis. Lung infiltrates or effusions may worsen or develop. It is important to exclude multi-drug resistance in all patients with suspected paradoxical TB IRIS.
Other common IRIS manifestations include:
- Inflammatory reactions to skin diseases, especially acne and Kaposi’s sarcoma.
- Worsening cryptococcal meningitis.
- Flares of hepatitis B or C.
GENERAL MEASURES
Counselling is important to ensure that the patient understands that IRIS does not mean failure of ART.
Management of IRIS is mainly symptomatic, e.g. aspiration of TB lymph nodes or effusions.
Continue ART and therapy for the opportunistic infection.
MEDICINE TREATMENT
For pain and fever:
- Paracetamol, oral, 500 mg-1 g 4–6 hourly as required. (to a maximum of 4g in 24 hours).
- Maximum dose: 15 mg/kg/dose.
OR
- NSAIDs, e.g.:
- Ibuprofen, oral, 400 mg 8 hourly with meals.
Treatment for severe IRIS manifestations (e.g. compression of major structures by enlarging lymph nodes, expanding CNS tuberculomata, worsening meningitis):
- Corticosteroids (intermediate-acting) e.g.:
- Prednisone, oral, 1.5 mg/kg daily for 2 weeks.
- Then 0.75 mg/kg daily for 2 weeks.
Prophylaxis for paradoxical TB IRIS in high-risk patients (CD4 ≤100 cells/mm3 ) who have had antituberculosis treatment for <30 days before initiating ART:
- Corticosteroids (intermediate-acting) e.g.:
- Prednisone, oral, 40 mg daily for 2 weeks.
- Then 20 mg daily for 2 weeks.
LoE:IIaxxxi
Note:
Do not use steroids in patients with Kaposi sarcoma.
Standard Treatment Guidelines and Essential Medicines List for South Africa, Adult Hospital Level, 2020-2024_Version 2.1_09 December 2024
Chapter 10 HIV and AIDS_10.1 Antiretroviral Therapy_10.1.2 Immune Reconstitution Inflammatory Syndrome (IRIS)