Immune Reconstitution Inflammatory Syndrome Presenting as Psoriasis After Initiating Antiretroviral Therapy: A Case-Report.

The burden of HIV and AIDS has been reduced with the utilization of combination antiretroviral therapy (cART). Immune reconstitution inflammatory syndrome (IRIS) is a complication seen with either the initiation or the reintroduction of cART. Although multiple IRIS definitions have been used, there is still no consensus on a clinically useful definition. Based on the pathophysiology, IRIS can be clinically grouped into two categories: it is either caused by a previously subclinical infection that was unmasked by the immune response following the initiation of ART (unmasking IRIS) or by the paradoxical relapse of a recently treated opportunistic infection (paradoxical IRIS). Psoriasis is seen with advanced HIV and immunosuppression and its symptoms typically recede after the initiation of cART and immune restoration. Three theories have been proposed to explain psoriasis in HIV: an imbalance in the CD8+ T-cells to CD4+ T-cells ratio, an imbalance of regulatory T cells (Treg), and HIV acting as a co-stimulatory factor to CD8+ T-cells. However, in this case report, we are describing the paradoxical presentation of IRIS as psoriasis, seen after reinitiating of cART. To our knowledge, this is the second reported case in the literature. We are describing a case of a 39-year-old Lebanese man with long-standing HIV infection and poor cART compliance over the past eight years. The patient has had three flares of psoriasis that coincided with the re-initiation of cART. We are proposing that this patient’s noncompliance with cART and the resulting low, non-recovering CD4/CD8 ratio lead to IRIS presenting as psoriasis. Additionally, a dysfunction in Treg may be another probable explanation for IRIS psoriasis similar to the dysfunction seen with HIV associated psoriasis. Therefore, we conclude that IRIS can present as psoriasis; however, more research is needed in order to make the picture of these complex immune phenomena clearer.