Syndrome inflammatoire de reconstitution immune (IRIS) associé Ã la tuberculose

The main clinical manifestations of tuberculosis-associated immune reconstitution inflammatory syndrome (IRIS) are the appearance or the worsening of tuberculosis lesions (fever, adenopathies, pleural effusion, pleural infiltrate…) after an initial improvement. Physiopathology includes a reconstitution of an exaggerated specific T cell response against tuberculosis antigens probably mediated by innate immunity under the control of the host genetic polymorphism. Tuberculosis therapy alone could be responsible of IRIS also called paradoxical worsening, however IRIS is more frequent after antiretroviral therapy initiation in HIV tuberculosis co-infected patient. Despite the definition of clinical criteria, the diagnosis remains difficult and need to eliminate a failure (resistance, non adherence) or an adverse effect of tuberculosis treatment. Main IRIS risk factors are tuberculosis dissemination, immunodepression and early antiretroviral therapy initiation. Prognosis is usually favourable except in case of neurological involvement. Therapeutic strategies of IRIS remain controversial. The outcome, usually favourable without specific treatment, is an argument for therapeutic abstention in non-severe IRIS. Steroids allow a shortening of IRIS symptoms, however their use is associated with relapses which suggested that they could be reserved for severe IRIS where they are recommended. The development of therapeutic and preventive strategies is needed considering the high frequency of IRIS especially in high endemic countries of HIV and tuberculosis.