Cryptococcal meningitis in an HIV-1-infected person: relapses or IRIS? Case report and review of the literature

After starting highly active antiretroviral therapy (HAART), HIV-infectedpatients may experience what is termed immune reconstitution inflammatorysyndrome (IRIS). IRIS is characterized by a paradoxical inflammatory response to either previously or recently treated infections or unmasked subclinicalinfections, when the patient regains the ability to mount a suitable immuneresponse against specific antigens or pathogens. Cryptococcal IRIS (C-IRIS) isthought to be mediated by recovery of Cryptococcus-specific immune responses,resulting in exaggerated host inflammatory responses. In HIV-positive subjects,two distinct modes of presentation of C-IRIS are recognized, "paradoxical" and"unmasking" C-IRIS. "Paradoxical" C-IRIS presents as worsening or recurrence oftreated cryptococcal disease following HAART initiation, despite microbiological treatment success. In the "unmasking" form, patients with no prior diagnosis may develop acute symptoms of cryptococcosis, such as meningitis or necrotizinglymphadenopathy, after starting HAART. Here, we present the case of anHIV-positive man, who developed cryptococcal meningitis two months after havingstarted HAART and experienced several meningeal relapses and a "paradoxical"C-IRIS during the following year.