With regard to tuberculosis, although paradoxical IRIS associated with UK-371804 chemical structure Mycobacterium tuberculosis occurs in over 45% of individuals, CNS complications are presumed to be much lower [37]. In our cohort, just one case

of IRIS was related to tuberculosis. In two recent studies of 80 and 144 patients coinfected with tuberculosis and HIV, no cases of CNS-associated complications were reported [38]. In our study, none of the patients who presented a paradoxical IRIS had a previous history of any AIDS-defining opportunistic infection. Previous studies had suggested that patients previously undiagnosed with HIV infection presented a higher risk for the development of paradoxical IRIS if a CNS opportunistic infection was the AIDS-defining illness [4]. We did not find any other clinical or immunological parameter at baseline that predicted the development of IRIS after initiation of HAART. As previously described, in our cohort baseline CD4 cell count was not predictive of developing paradoxical IRIS [4, 39, 40]. However, patients who developed paradoxical IRIS had a more rapid immune restoration in response to HAART than patients who did not. This is consistent with findings from both retrospective and prospective analyses which revealed

a greater CD4 response in patients developing IRIS [7, 9, 40-42]. As previously indicated, no differences in the risk of developing IRIS were observed when protease inhibitor-containing regimens were compared with other regimens Vincristine datasheet [11, 39]. In our cohort, initiation of HAART during the first 2 weeks after the diagnosis of a neurological infection was not associated with a higher risk for the development of paradoxical IRIS. However, the retrospective design of our study and the low number of patients with IRIS limit the significance of this observation. Optimal timing for initiation of HAART is still a controversial issue in patients

with CNS opportunistic infections. Nowadays we have consistent data that indicate the benefits of early HAART in patients with opportunistic infections, even in those with tuberculosis [43]. However, in none of these studies were patients with CNS infections sufficiently represented. In some retrospective studies of patients with cryptococcal meningitis, below beginning HAART within 30–60 days of the treatment of meningitis has been associated with a higher risk of paradoxical IRIS and a higher mortality rate [4, 40]. In contrast, a prospective multicentre study did not identify an association between the timing of HAART and the development of IRIS [36]. Finally, a recent prospective study performed in sub-Saharian Africa showed a risk of mortality 3 times greater in HIV-infected patients who had begun ART within 72 h after cryptococcal meningitis diagnosis than in those in whom HAART was delayed for 10 weeks [13]. Development of IRIS seems not to worsen prognosis in patients with CNS opportunistic infections.