Machava Percina, Joaquim Winete, Borrell Joseph, Richardson Shannon, Cassia Uneisse, Sidat Muhammad, Maieca Alice, Massitela Cláudia, Quelhas Yara, Mucuila Cafrina, Elias Beatriz, da Rocha Massada, Schaaf H Simon, Buck W Chris
Hospital Central de Maputo, Maputo, Mozambique.
Universidade Eduardo Mondlane Faculdade de Medicina, Maputo, Mozambique.
AIDS Res Ther. 2024 Apr 27;21(1):25. doi: 10.1186/s12981-024-00614-7.
Bacillus Calmette-Guérin (BCG) reactions are the most common cause of immune reconstitution inflammatory syndrome (IRIS) in HIV-positive infants who initiate antiretroviral therapy (ART). There is limited evidence regarding the incidence of BCG-IRIS; however, reports from outpatient cohorts have estimated that 6-9% of infants who initiated ART developed some form of BCG-IRIS within the first 6 months. Various treatment approaches for infants with BCG-IRIS have been reported, but there is currently no widely accepted standard-of-care.
A 5-month-old male HIV-exposed infant BCG vaccinated at birth was admitted for refractory oral candidiasis, moderate anemia, and moderate acute malnutrition. He had a HIV DNA-PCR collected at one month of age, but the family never received the results. He was diagnosed with HIV during hospitalization with a point-of-care nucleic acid test and had severe immune suppression with a CD4 of 955 cells/µL (15%) with clinical stage III disease. During pre-ART counseling, the mother was educated on the signs and symptoms of BCG-IRIS and the importance of seeking follow-up care and remaining adherent to ART if symptoms arose. Three weeks after ART initiation, he was readmitted with intermittent subjective fevers, right axillary lymphadenopathy, and an ulcerated papule over the right deltoid region. He was subsequently discharged home with a diagnosis of local BCG-IRIS lymphadenitis. At six weeks post-ART initiation, he returned with suppurative lymphadenitis of the right axillary region that had completely eviscerated through the skin without signs of disseminated BCG disease. He was then started on an outpatient regimen of topical isoniazid, silver nitrate, and oral prednisolone. Throughout this time, the mother maintained good ART adherence despite this complication. After 2.5 months of ART and one month of specific treatment for the lymphadenitis, he had marked mass reduction, improved adenopathy, increased CD4 count, correction of anemia, and resolution of his acute malnutrition. He completely recovered and was symptom free two months after initial treatment without surgical intervention.
This case details the successful management of severe suppurative BCG-IRIS with a non-surgical approach and underlines the importance of pre-ART counseling on BCG-IRIS for caregivers, particularly for infants who initiate ART with advanced HIV.
卡介苗（BCG）反应是开始抗逆转录病毒治疗（ART）的HIV阳性婴儿中免疫重建炎症综合征（IRIS）最常见的原因。关于卡介苗-IRIS发病率的证据有限；然而，门诊队列报告估计，开始接受ART治疗的婴儿中有6-9%在最初6个月内出现了某种形式的卡介苗-IRIS。已有多种针对卡介苗-IRIS婴儿的治疗方法的报道，但目前尚无广泛接受的标准治疗方案。
一名5个月大的男性婴儿，出生时接种了卡介苗，因难治性口腔念珠菌病、中度贫血和中度急性营养不良入院。他在1个月大时进行了HIV DNA-PCR检测，但家人从未收到检测结果。住院期间通过即时核酸检测诊断为HIV感染，免疫严重抑制，CD4细胞计数为955个/µL（15%），临床分期为III期。在ART治疗前咨询期间，向母亲介绍了卡介苗-IRIS的体征和症状，以及出现症状时寻求后续治疗并坚持ART治疗的重要性。开始ART治疗三周后，他因间歇性主观发热、右腋窝淋巴结肿大以及右三角肌区域出现溃疡丘疹再次入院。随后他被诊断为局部卡介苗-IRIS淋巴结炎出院回家。在开始ART治疗六周后，他因右腋窝区域化脓性淋巴结炎再次就诊，淋巴结已完全破溃至皮肤表面，无播散性卡介苗病迹象。随后他开始接受门诊局部异烟肼、硝酸银和口服泼尼松龙治疗方案。在此期间，尽管出现了这一并发症，母亲仍坚持良好的ART治疗依从性。经过2.5个月的ART治疗和1个月的淋巴结炎特异性治疗后，他的肿块明显缩小，淋巴结病改善，CD4细胞计数增加，贫血得到纠正，急性营养不良得到缓解。他完全康复，初始治疗两个月后无症状，无需手术干预。
本病例详细介绍了采用非手术方法成功治疗严重化脓性卡介苗-IRIS的过程，并强调了ART治疗前对护理人员进行卡介苗-IRIS咨询的重要性，特别是对于开始接受ART治疗的晚期HIV感染婴儿。
