认识免疫重建炎症综合征课件讲义

安徽省医学会重症医学分会第十二次年会认识免疫重建炎症综合征安徽医科大学第二附属医院孙昀金2019.10.31CaseReportA35-year-oldmalewithan8-yearhistoryofAIDSpresentedwitha3dayhistoryofrecurrentfrontalheadaches,subjectivefeverandalteredmentalstatusHehadahistoryofnon-adherencetomedicationsbuthehadresumedantiretroviraldrugsforabout10weeksFourweekspriortopresentationtoourhospital,hehadbeendiagnosedwithcryptococcalmeningitis(CM)inanoutsidehospitalandhadreceiveda7daycourseofintravenousamphotericinB(lipidcomplexpreparationThiswasdiscontinuedduetoprogressiveacutekidneyinjuryandhewassubsequentlyplacedonhighdose(800mgoralfluconazole(flu)dailyInfectiousDiseaseReports2019volume6:5576CaseReportFigure1.Braiaxialandcoronalviewsshysticstructureswithinthelateralventriclesperiventricularwhitematterareaandbasalglia.Thereisenlargementoftheventricularsystemaswell.B)showsadditionalcysticlesionssurroundingthefourthventricle.InfectiousDiseaseReports2019;volume6:5576CaseReportHewasreadmittedtothehospital5weekslaterwithrecurrentheadachesandfeversMRiofhisbrainshowednochangeTable1.TrendofCD4countandHIVviralload8weekspriortoinitialpresentation,aswellascerebrospinalfluidparametersandantifungalinductiontreatmentcoursesoftheindexpatientduringthefirst5monthsofhispresentationWeek-8Week1Week12Week4Week6Week20CSFCRAG>1024>1:10241:18>11024CSFopeningpressureNRNCSFWBC(lymphs)24(840)14(92%)2366%protetI+veastCSFculturec1growthNogrowthNogrowth物灿gohHIVVL(copies/mL)50.001740detected<20CD4count(cellspL)9(nadir16AntifungalinductiontherapyAmB(Iweek)LAmWeeklrisitwasataseparatehospitalCSf,cerehrospnalluid,CRA,Cryptococcalantigen;NR,notreported,WBC,whilebloodcels,VL,vIalload,AmB,anpboteriinBdeoxycholateLAmB,IipusonaamphoteritinB:5-FCfcyasine.Thepatietwashospitalisedonweeks1,5,[.InfectiousDiseaseReports2019;volume6:5576发现HIVinfectionischaracterizedbyagradualreductioninthecountsofCD4+lymphocytesopportunisticinfections(oI)andspecificneoplasticprocesseshighlyactiveantiretroviraltherapy(HaartdecreaseinviralloadimprovementinCD4+TcellcountsreducestheOiandprolongedalsurvIv:fewpatientsexperienceaclinicaldeteriorationduetodysbalancedrestorationoftheCD4TcelloftheimmunesystemJournalofTnternationalOralHealth2019;7(4):92-95命名起初免疫修复疾病(imunereeonstitutiodisease,IRD)免疫重建病(immunereconstitutionsyndrome,IRS)ftal2019npatientwthpeniseshistoryofirsetien,raine鉴于宿主的炎性反应在发病中的重要作用opoortrensiepousinDesimone等首次提出免疫重建炎性综合征。國(immunereconstitutioninflammationsyndromeIRIS临床表现根据涉及的感染性或非感染性因子的不同而不同分枝杆菌引起的淋巴结病、结核病的异常表现>进展性多灶性脑白质病的恶化耶氏肺孢子菌肺炎弓形虫病的复发巨细胞病毒性视网膜炎病毒性肝炎>有些则可能表现为自身免疫性疾病Riswhichmaymanifestasanewlyidentifiedopportunisticinfection(ol)inouslyasymptomaticindividuals(unmaskingIRiS)orwithparadoclinicalworseningofaknownol(paradoxicalIRIS)IRIS的危害部分患者不能耐受现有的治疗或对ART药物的作用产生怀疑自行停止ART服药的依从性降低,导致诱发HV耐药变异的产生与传播,影响ART的远期治疗效果和未来治疗的选择增加住院率,降低患者生活质量,提高艾滋病防治工作成本;IRS的表现常被误判为抗OI病原体治疗无效所引起的一系列表现,导致对其治疗方案的不适当调整。少数患者因IRIS死亡;影响患者的远期免疫功能重建,研究表明部分发生IRIS的患者,ART3-4年后CD细胞的恢复仍受到景响。MedmycolCaseRep:2019:5:16-9IRIS的发病率艾滋病患者在接受ART后6个月内IRS的发病率欧美发达国家为10%~15%资源有限的发展中国家为20%~25%绝大多数发生于治疗的前3个月JpnJldeaDis,2019,61:205A|DS,2019,601-10IRIS的发病机制体液免疫相关的辅助性T细胞在介导机体与外源性抗原的免疫反应中起重要作用。同源性配体激发Th0细胞初始CD4T细胞)在不同细胞因子的作用下进行分化Th