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

After starting highly active antiretro - viral therapy (HAART), HIV-infected patients may experience what is termed immune reconstitution inflammatory syndrome (IRIS). IRIS is characterized by a paradoxical inflammatory response to either previously or recently treated infections or un - masked subclinical infections, when the patient re - gains the ability to mount a suitable immune re - sponse against specific antigens or pathogens. Cryptococcal IRIS (C-IRIS) is thought to be mediat - ed by recovery of Cryptococcus-specific immune responses, resulting in exaggerated host inflamma - tory responses. In HIV-positive subjects, two dis - tinct modes of presentation of C-IRIS are recog - nized, "paradoxical" and "unmasking" C-IRIS. "Paradoxical" C-IRIS presents as worsening or re - currence of treated 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 necrotizing lymphadenopathy, after starting HAART. Here, we present the case of an HIV-positive man, who developed cryptococcal meningitis two months after having started HAART and ex - perienced several meningeal relapses and a "paradoxical" C-IRIS during the following year.