Vaselli Natasha Marcella, Salaveria Kris, Winearls James, Garnham Katherine
Department of Infectious Diseases, Gold Coast University Hospital, Southport, Queensland, Australia.
Institute of Infection, Veterinary & Ecological Sciences, University of Liverpool, Liverpool, UK.
HIV Med. 2025 Jun;26(6):839-848. doi: 10.1111/hiv.70016. Epub 2025 Mar 24.
Immune reconstitution inflammatory syndrome (IRIS) can occur in patients with HIV after commencing antiretroviral therapy. Tuberculosis-IRIS is the most common, and Pneumocystis jirovecii pneumonia (PJP)-IRIS accounts for only 2.7%-4% of IRIS cases. The prognosis and management of IRIS is well studied in other opportunistic infections but is ill defined for PJP-IRIS, and no guidelines exist. We reviewed the literature to consolidate the available data for PJP-IRIS to formulate recommendations for the diagnosis and management of this condition.
We performed a literature review of cases of PJP-IRIS and included cases in Australia that had not been previously published. We searched the Web of Science, MEDLINE, Embase, SCOPUS databases and grey literature sources for studies reporting cases of PJP-IRIS between January 1981 and August 2024. We provide a synthesis of published cases evaluating pathogenesis, mortality, and therapeutic options.
In total, 51 patients were identified from 25 data sources. Two mortalities were described. We found that 22% of PJP-IRIS cases required support in the intensive care unit. Antimicrobial treatment for PJP was given in 32 cases, and trimethoprim-sulfamethoxazole was the most prescribed. Extending the duration of PJP therapy beyond the usual 21 days did not appear to affect outcomes. Corticosteroids were given in 26 (52%) cases, not given in 12 cases (20%), and use was not stated in 13 cases (26%). The type and dose of steroid used varied and was described in 15 cases.
Mortality in PJP-IRIS appears lower than in IRIS secondary to other opportunistic infections. Prompt treatment with corticosteroids at a dose proportionate to disease severity is recommended. Extending antimicrobials for PJP beyond 21 days does not appear to offer clinical benefit in patients with PJP-IRIS. With the rise of immunotherapy, new treatments could be on the horizon for PJP-IRIS.
免疫重建炎症综合征（IRIS）可发生于开始抗逆转录病毒治疗后的HIV患者。结核性IRIS最为常见，而耶氏肺孢子菌肺炎（PJP）相关的IRIS仅占IRIS病例的2.7%-4%。IRIS在其他机会性感染中的预后和管理已得到充分研究，但PJP-IRIS的情况尚不明确，且尚无相关指南。我们回顾了文献，以整合PJP-IRIS的现有数据，为该病的诊断和管理制定建议。
我们对PJP-IRIS病例进行了文献回顾，并纳入了澳大利亚此前未发表的病例。我们在科学网、MEDLINE、Embase、SCOPUS数据库及灰色文献来源中搜索了1981年1月至2024年8月期间报告PJP-IRIS病例的研究。我们对已发表病例进行了综合分析，评估其发病机制、死亡率及治疗选择。
共从25个数据源中识别出51例患者。描述了2例死亡病例。我们发现，22%的PJP-IRIS病例需要重症监护病房的支持。32例患者接受了针对PJP的抗菌治疗，最常使用的是复方新诺明。将PJP治疗时间延长至通常的21天以上似乎并未影响治疗结果。26例（52%）患者使用了皮质类固醇，12例（20%）未使用，13例（26%）未说明使用情况。使用的类固醇类型和剂量各不相同，15例中有描述。
PJP-IRIS的死亡率似乎低于其他机会性感染所致的IRIS。建议根据疾病严重程度及时给予适当剂量的皮质类固醇治疗。对于PJP-IRIS患者，将PJP抗菌药物治疗时间延长至21天以上似乎并无临床益处。随着免疫治疗的兴起，PJP-IRIS可能会有新的治疗方法出现。
