BioMed CentralInfectious Agents and Cancer ss Open AcceOral presentation Kaposi's sarcoma-associated immune reconstitution inflammatory syndrome (KS-IRIS) in Africa: initial findings from a prospective evaluation JN Martin*1, M Laker2, A Kambugu2, D Janka1, J Orem3, A Mwaka3, T Maurer1 and EK Mbidde4 Address: 1University of California, San Francisco; California, USA, 2Infectious Diseases Institute, Kampala, Uganda, 3Uganda Cancer Institute, Kampala, Uganda and 4Uganda Virus Research Institute, Entebbe, Uganda * Corresponding author Background Immune reconstitution inflammatory syndrome (IRIS) is a set of conditions, characterized by findings of inflamma- tion, which occur in HIV-infected patients after initiation of antiretroviral therapy (ART). It is believed to result from an overly exuberant response to residual opportunistic pathogens by the newly reconstituted immune system. Specific manifestations of IRIS depend upon the pathogen being targeted, but among the variants of IRIS, Kaposi's sarcoma-associated IRIS (KS-IRIS) is one of the least understood – especially in resource-limited settings where KS is epidemic. Now that ART is becoming available in sub-Saharan Africa, we have hypothesized that KS-IRIS is likely to be most relevant in this region. This is because of the high prevalence of AIDS-related KS in sub-Saharan Africa (i.e., large number of patients with AIDS-KS initiat- ing ART) and because of factors that theoretically may pre- dispose to KS-IRIS, specifically higher KS lesion burden and lower pre-ART CD4+ T cell count. Methods In Kampala, Uganda, we studied the incidence and spec- trum of KS-IRIS in a randomized trial for the initial ther- apy of AIDS-related KS. Participants without indications for chemotherapy were randomized to one of two differ- ent ART regimens and then evaluated every 4 weeks for 48 weeks with a questionnaire, physical examination, and digital photography to record signs and symptoms com- patible with KS-IRIS. KS-IRIS was defined as development of a) any of the following in pre-existing KS lesions: swell- ing, pain or tenderness, paresthesia, erythema, or warmth; or b) not otherwise explained subcutaneous nodules, node enlargement, edema, or pleural effusion. Results Of the first 30 subjects evaluated, 17 (57%) exhibited ≥ 1 sign or symptom compatible with KS-IRIS. The most com- mon finding was lesion swelling (43%), and there were several instances of dramatic lesion enlargement followed by spontaneous reduction (see Figures 1 and 2 from two subjects). Other manifestations included lesion pain or pares-thesia (33%), warmth or erythema (23%), femoral or inguinal node enlargement with scrotal swelling (n = from 11th International Conference on Malignancies in AIDS and Other Acquired Immunodeficiencies (ICMAOI): Basic, Epidemiologic, and Clinical Research Bethesda, MD, USA. 6–7 October 2008 Published: 17 June 2009 Infectious Agents and Cancer 2009, 4(Suppl 2):O17 doi:10.1186/1750-9378-4-S2-O17 <p>Proceedings of the 11th International Conference on Malignancies in AIDS and Other Acquired Immunodeficiencies (ICMAOI): Basic, Epidemiologic, and Clinical Research</p> Publication of this supplement was made possible with support from the Office of HIV and AIDS Malignancy, National Cancer Institute, National Institutes of Health. Meeting abstracts – A single PDF containing all abstracts in this Supplement is available here. http://www.biomedcentral.com/content/pdf/1750-9378-4-S2-info.pdf This abstract is available from: http://www.infectagentscancer.com/content/4/S2/O17 © 2009 Martin et al; licensee BioMed Central Ltd. Figure 1 Page 1 of 2 (page number not for citation purposes) http://www.infectagentscancer.com/content/4/S2/O17 http://www.biomedcentral.com/ http://www.biomedcentral.com/info/about/charter/ Infectious Agents and Cancer 2009, 4(Suppl 2):O17 http://www.infectagentscancer.com/content/4/S2/O17 Publish with BioMed Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp BioMedcentral 1), and pleural effusion (n = 1). The most fulminant KS- IRIS case featured diffuse lesion swelling and new diffuse subcutaneous nodules; death ensued but the causative role of KS-IRIS is unknown. Of the three participants with KS-IRIS that did not resolve spontaneously and who were given chemotherapy, two had a good response to lipo- somal doxorubicin. Conclusion In sub-Saharan Africa, KS-IRIS occurs at a clinically rele- vant frequency with a wide spectrum of manifestations. Many of the findings are difficult to distinguish in real time from natural KS progression, and even some of the most dramatic cases can be self-limiting. This, coupled with the general lack of effective chemotherapy for KS in resource-limited settings, makes patient management complicated when KS-IRIS is suspected. In this setting, diagnostic tests are thus urgently needed to distinguish IRIS-based disease from natural progression of KS. Figure 2 Page 2 of 2 (page number not for citation purposes) http://www.biomedcentral.com/ http://www.biomedcentral.com/info/publishing_adv.asp http://www.biomedcentral.com/ Background Methods Results Conclusion