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Corticosteroids Contraindicated KS-IRIS — SCE Infectious Diseases MCQ

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HardHIV MedicineCorticosteroids Contraindicated KS-IRISSCE Infectious Diseases

A 35-year-old man with HIV (CD4 200, recently started ART 3 weeks ago) develops acute worsening of pre-existing Kaposi sarcoma skin lesions. His VL has dropped from 180,000 to 12,000. Some lesions are newly inflamed with surrounding oedema. Unlike TB-IRIS, corticosteroids should be AVOIDED in KS-IRIS. Why?

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Correct answer: C — Corticosteroids enhance HHV-8 viral replication and may worsen KS — HHV-8 encodes viral genes responsive to glucocorticoid receptor activation

HHV-8 encodes several genes with glucocorticoid response elements in their promoters. Corticosteroid exposure activates HHV-8 lytic replication and enhances viral gene expression, potentially worsening KS. This is why corticosteroids are generally avoided in KS-IRIS (unlike TB-IRIS or cryptococcal IRIS where corticosteroids are beneficial). The management of KS-IRIS is: continue ART (never stop) plus systemic chemotherapy (liposomal Doxorubicin) for progressive/symptomatic KS.

Reference: BHIVA 2022 – KS and IRIS; Lancet Oncol 2019 – KS pathogenesis