背景:卡介苗(BCG)反应是开始抗逆转录病毒治疗(ART)的HIV阳性婴儿免疫重建炎症综合征(IRIS)的最常见原因。关于BCG-IRIS发生率的证据有限;然而,来自门诊队列的报告估计,6-9%开始ART的婴儿在前6个月内出现了某种形式的BCG-IRIS.已经报道了BCG-IRIS婴儿的各种治疗方法,但是目前还没有被广泛接受的护理标准。
方法:一名出生时接种BCG的5个月大的男性HIV暴露婴儿因难治性口腔念珠菌病入院,中度贫血,和中度急性营养不良。他在一个月大的时候收集了一个HIVDNA-PCR,但是这个家庭从未收到结果。他在住院期间通过即时核酸检测被诊断为HIV,并且具有严重的免疫抑制,CD4为955个细胞/µL(15%),患有临床III期疾病。在ART前咨询期间,对母亲进行了BCG-IRIS的体征和症状方面的教育,以及在出现症状时寻求后续治疗和坚持ART治疗的重要性.ART开始三周后,他因间歇性主观发烧再次入院,右腋窝淋巴结病,右三角肌区域有一个溃疡丘疹。他随后出院,诊断为局部BCG-IRIS淋巴结炎。ART开始后六周,他因右侧腋窝区域化脓性淋巴结炎而返回,该淋巴结炎已完全通过皮肤清除内脏,而没有播散性BCG疾病的迹象。然后他开始接受局部异烟肼的门诊治疗方案,硝酸银,和口服泼尼松龙。在这段时间里,尽管出现了这种并发症,但母亲仍保持良好的ART依从性。经过2.5个月的ART和一个月的淋巴结炎的特定治疗,他有明显的质量减少,改善腺病,CD4计数增加,纠正贫血,和解决他的急性营养不良。他完全康复,在没有手术干预的初始治疗后两个月无症状。
结论:本案例详细介绍了采用非手术方法成功治疗严重化脓性BCG-IRIS,并强调了对护理人员进行BCG-IRIS前ART咨询的重要性。特别是对于使用晚期HIV开始ART的婴儿。
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.