Immune Restoration Disease in HIV-Infected Patients after Antiretroviral Therapy

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Abstract
Sir—We were interested to read the paper on “immunorestitution disease” by Cheng et al. [1], since we, too, have argued for several years that infectious and/or inflammatory disease in HIV-infected patients who are responding to antiretroviral therapy (ART) is a manifestation of immune restoration. When zidovudine monotherapy was introduced into clinical practice, our group observed that Mycobacterium avium complex (MAC) disease developed in a small proportion of patients during the first few weeks of therapy and that this development was associated with the restoration of a delayed-type hypersensitivity (DTH) response to mycobacterial antigens [2]. We argued that this reflected restoration of an immune response against subclinical MAC infection [3]. Disease presentation was atypical; in particular, the infection was usually localized to tissues rather than disseminated. After the introduction of highly active ART (HAART), we again observed cases of MAC disease presenting in a similar way, and we also observed infectious and/or inflammatory disease caused by other pathogens [4–6]. As argued elsewhere [4, 7], we believe that these disease events also reflected the restoration of pathogen-specific immune responses, and we have proposed the term “immune restoration disease” (IRD) to designate them [4, 7–9].