Rheumatic manifestations associated with human immunodeficiency virus infection

Human Immunodeficiency Virus Infection: Spectrum of Rheumatic Manifestations

Emerging and reemerging viral infections have been a characteristic feature of the past several decades, with HIV infection being the most important example of an emergent viral infection. To date, the status of a considerable proportion of HIV/AIDS patients has changed from a near-fatal disorder secondary to opportunistic infections to a chronic disease in which a variety of co-morbid conditions have become prevalent and relevant. Arthralgia and myalgias are the most common symptoms. The rate of spondyloarthritis varies according to the geographic area, genetic and mode of transmission. Most RA and SLE patients might go into remission after the development of AIDS, but also there are patients that continue with active disease. Prevalence of DILS is highest among African Americans in less advanced stages. PAN is clinically less aggressive and peripheral neuropathy is the most common clinical manifestation. Anti-phospholipid syndrome (APS), systemic sclerosis and poly-dermatomyositis are uncommon. After the introduction of combination antiretroviral therapy (cART), a decline of spondyloarthritis disorders and of DILS and development of new syndromes such as IRIS, osteoporosis and avascular bone necrosis have occurred. The treatment of patients with rheumatic diseases and HIV infection remains a challenge.

Arthritis in childhood human immunodeficiency virus infection predominantly associated with human leukocyte antigen B27

AIM

Children with human immunodeficiency virus (HIV) infection usually present with recurrent and unusual infections. Although reported among adults, arthritis as a predominant presentation in children with HIV is rare. Reactive arthritis is considered to be the most common musculoskeletal manifestation in adults with HIV infection. However, in children, septic or HIV-related arthritis has been described. We report four children having arthritis with HIV disease and their long-term outcome; out of which three had human leukocyte antigen (HLA)-B27-related arthritis. It is important to be aware of arthritic presentation of HIV disease in children to prevent delay in diagnosis and initiation of appropriate therapy.

METHODS

Clinical profile of children with HIV infection who presented with arthritis and registered at the Pediatric Immunodeficiency Clinic at PGIMER, Chandigarh were reviewed and analyzed.

RESULTS

A total of 796 children with HIV infection are registered in the Pediatric Immunodeficiency Clinic since January 1994. Among these, four children had arthritis, and it was the presenting manifestation in two of them. HLA-B27 related arthritis was noted in three children, while one had HIV-associated arthritis. None of the children had septic arthritis. Arthritis resolved on treatment with antiretroviral therapy (ART) in two children, while others responded to anti-inflammatory agents and the joint symptoms remained quiescent on follow-up with a total follow-up period of 21.5 patient years.

CONCLUSIONS

Clinicians must be aware of the arthritic presentation of childhood HIV infection. High degree of suspicion must be entertained to screen for HIV infection in children with arthritis, especially in those with reactive arthritis.

Etanercept for the treatment of human immunodeficiency virus-associated psoriatic arthritis

Etanercept may play an important role in modulating the inflammatory activity and progression of human immunodeficiency virus (HIV)-associated psoriasis and psoriatic arthritis. We report the case of a 45-year-old homosexual man with a CD4 cell count of less than 0.05 x 10(9)/L and an HIV viral load of 4200 copies/mL (while receiving highly active antiretroviral therapy) who developed extensive psoriatic plaques, 4.5-kg weight loss, onychodystrophy, and psoriatic arthropathy with severe periarticular bone demineralization. The arthritis progressed despite the use of several disease-modifying medications, including corticosteroids, hydroxychloroquine, and minocycline. Because of uncontrolled, progressive, and disabling arthritis and resulting profound disability, he was treated with etanercept. Within 3 weeks, his psoriasis had improved dramatically and his joint inflammation had stabilized. For the next 4 months, immunologic and viral parameters remained stable, but his clinical course was complicated by frequent polymicrobial infections. Etanercept was thus discontinued despite continued improvements in his psoriasis, psoriatic arthritis, and functional status. While both cutaneous and joint manifestations of psoriasis improved dramatically, the experience with this patient dictates that caution and careful follow-up must be exercised when prescribing etanercept in the setting of HIV infection.

Accumulation of human T lymphotropic virus type I-infected T cells in the salivary glands of patients with human T lymphotropic virus type I-associated Sjögren's syndrome

OBJECTIVE

To clarify the involvement of human T lymphotropic virus type I (HTLV-I) in the pathogenesis of Sjogren's syndrome (SS).

METHODS

In HTLV-I-seropositive patients with SS, HTLV-I proviral DNA in the labial salivary glands (SG) was detected by polymerase chain reaction (PCR) amplification of the extracted cellular DNA, and the localization in the SG was examined by in situ PCR hybridization.

RESULTS

The cellular DNA extracted from the SG contained full HTLV-I proviral DNA, which was present in the nucleus of the infiltrating T cells, but not in either the SG epithelial cells or the acinar cells. Furthermore, the viral loads in the SG were approximately 8 times to 9 x 10(3) times higher than those in the peripheral blood mononuclear cells.

CONCLUSION

Accumulation of HTLV-I-infected T cells in the SG suggests that HTLV-I likely causes the self-reactive T cells to proliferate, which, as a result, induces SS.

Pain as a complication of HIV disease

Pain as a symptom is common to many pathologic conditions. At its most elementary level, it is a signal from peripheral nerves with specialized receptors that there is a change in the local environment, such as pressure, pH, temperature, or some other noxious stimulus, that can be detrimental to function. Pain is particularly prevalent in patients with HIV infection. The assessment, evaluation, and treatment of pain should be an integral part of comprehensive patient care.

Toxoplasmic polymyositis revisited: case report and review of literature

Toxoplasmosis can cause polymyositis either by reactivation or by recent infection. Inconsistent response to antiprotozoal therapy has been the strongest argument against toxoplasmic polymyositis as a separate entity. We report a biopsy-proven case of toxoplasmic polymyositis in a cardiac transplant patient presenting with a severe proximal weakness, myopathic, electromyographic changes and ten-fold increase of anti-Toxoplasma antibodies. An early antiprotozoal therapy and plasmapheresis led to recovery. A review of previously reported cases of toxoplasmic polymyositis suggests that an early antiprotozoal therapy is the most important variable affecting the outcome of this disease. We propose that toxoplasmic polymyositis has two phases: acute, responsive to antiprotozoal therapy, and chronic, manifested by altered immune response requiring steroids. We suggest that all patients presenting with polymyositis should have serological tests for toxoplasmosis as a part of their initial evaluation and an early trial of antiprotozoal therapy in case of positive findings.

Osteoarticular and muscle infectious lesions in patients with the human immunodeficiency virus

Between 1988 and 1995, 1832 HIV positive patients were evaluated in our institution. We studied the epidemiologic, immunologic and bacteriologic data, laboratory tests, and X-Ray films in those with musculoskeletal infection. We reviewed twenty-one cases of musculoskeletal infection in twenty patients aged 23-35 years (mean 28,6 years, M:F= 15:5). In all of them risk factor for HIV was intravenous drug abuse. The number of CD4 positive lymphocytes ranged from 0,003 to 0,5 10(9)/l. Staphylococcus aureus was the organism responsible of the infection in twelve cases, all active intravenous drug abusers at the time the diagnosis was done. The remaining causative agents were: Mycobacterium tuberculosis (3 cases), Candida albicans (2 cases), Salmonella subgroup 1 (1 case), Neisseria gonorrhoeae (1 case), Pseudomona aeruginosa (1 case) and Streptococcus agalactiae (1 case). Fifteen infections were diagnosed between 1988 and 1991 and 6 between 1992 and 1995. Musculoskeletal infectious lesions in HIV positive patients in our country are related in the majority of cases to intravenous drug abuse. In the last four years due to a National medical health care plan conducted to educate this group of people the number of musculoskeletal infections is decreasing.

Musculoskeletal infections in patients with human immunodeficiency virus infection

Musculoskeletal infections constitute an unusual clinical manifestation in patients with human immunodeficiency virus (HIV) infection. Available information about patients' characteristics and their clinical course has been obtained mainly from case reports and small retrospective studies. Our retrospective study is the largest in the literature providing detailed information about the clinical and laboratory characteristics of HIV-infected patients with different musculoskeletal infections. We identified 30 patients with various infections of the musculoskeletal system during a 5-year period among a cohort of 3,000-4,000 HIV-infected patients, and we describe them along with all cases of musculoskeletal infections in patients with HIV reported in the literature since 1985. Septic arthritis was the most commonly reported infection of the musculoskeletal system. It usually affects young men with a median CD4 count of 241. The exact contribution of a previous history of intravenous drug abuse in the pathogenesis of septic arthritis is unclear from the present and previous studies. Staphylococcus aureus was the most commonly isolated agent (31.3%). Numerous atypical pathogens were also identified as causes of septic arthritis. Approximately 90% of patients recovered with appropriate antibiotic treatment. Osteomyelitis was a more serious infection which also affected young individuals but with lower CD4 counts (median, 41). Half the cases were due to atypical mycobacteria. The mortality rate in the previously reported cases and in our series was high (20%). Pyomyositis is an increasingly recognized infection of the striated muscles in HIV-infected patients. It affects almost exclusively males with advanced HIV infection (median CD4 count, 24). Most cases are due to Staphylococcus aureus (67%). Drainage of the involved muscle(s) accompanied by proper antibiotic treatment resulted in resolution of the infection in the majority of patients (90%). Although the incidence of musculoskeletal infections in patients with HIV from this and previous studies appears to be low (0.3%-3.5%), these infections add a significant morbidity and mortality in the affected individuals. Better understanding of their pathogenesis and clinical course would aid the proper diagnosis and management of these infections.

Neutralization of HIV type 1 infectivity by serum antibodies from a subset of autoimmune patients with mixed connective tissue disease

Mixed connective tissue disease (MCTD) is a rheumatic disorder with clinical similarities to HIV-1 infection, and with characteristic autoimmune anti-RNP antibodies specific for the U1 snRNP splicing complex. Anti-RNP antibodies cross-react with the HIV-1 surface, owing to multiple homologies between the gp120/41 envelope complex and the 70K protein of U1 snRNP. A key epitope of 70K, its RNA-binding site, is homologous to a dominant B and T cell epitope in the third variable loop (V3) of gp120. In this study, we tested the ability of anti-RNP sera to inhibit HIV-1 infectivity in vitro. Of nine sera tested, five were 70-99% effective in neutralizing one or more HIV-1 strains. One serum was > 99% effective in neutralizing HIV-1MN, and 86 and 77% effective against the primary isolates HIV-1(CO) and HIV-1(JR-FL), respectively, an efficacy equal to that of a pool of broadly neutralizing antibodies from HIV-1-infected subjects (HIVIG). The mean neutralizing titer of anti-RNP sera against HIV-1(JR-FL) was 3.9-fold higher than that of HIVIG. Neutralizing potency was associated with high reactivity to gp120 by ELISA, and with the presence of serum rheumatoid factor, known to enhance antibody neutralization of other viruses. The current findings provide further evidence that individuals unexposed to HIV-1 may develop immunologic resistance by alternative mechanisms, possibly including molecular mimicry, or exposure to as yet unidentified retroviruses. Thus MCTD, which involves both B and T cell reactivity to self-epitopes homologous to HIV-1, may elucidate new strategies for generating protective immunity to this virus.

Human T lymphotropic virus type I in arthropathy and autoimmune disorders

The progressive nature of the disease and the persistent inflammation affecting various organs are common features of idiopathic autoimmune disorders of unknown etiology. Therefore, the HTLV-I-associated disorders described in the present review are outstandingly important models for our understanding of the pathologic mechanisms of organ-specific immune disorders. HTLV-I arthropathy is characterized by chronic inflammatory and proliferative synovitis with lymphoid follicles and pannus formation in the affected joints, indistinguishable from the findings in idiopathic RA. The presence of the tax gene in HTLV-I-negative SS patients suggests that it is responsible for the exocrine gland abnormality, characterized by extensive lymphoproliferative epithelial lesions. Furthermore, the pulmonary lesions of HTLV-I bronchopneumonopathy are similar to those of idiopathic interstitial pneumonitis. Based on these observations, the clinical findings associated with the immunologic abnormalities in HTLV-I-infected patients provide us with valuable information for understanding the pathogenetic mechanisms of chronic inflammatory conditions associated with immune regulatory disorders. Although the clinical and pathologic features of the 2 common HTLV-I-associated disorders, ATL and HAM/TSP, have been well characterized and are clearly distinguishable from those of the idiopathic forms of these disorders, other HTLV-I-related autoimmune diseases, e.g., arthropathy, SS, or bronchopneumonopathy, are clinically indistinguishable from the idiopathic forms of the diseases. Such similarity may serve as a clue to the pathogenetic mechanisms of idiopathic autoimmune disorders.

Polyarteritis nodosa and HIV infection: no evidence of a direct pathogenic role of HIV

A case of polyarteritis nodosa identified by the American College of Rheumatology (ACR) 1990 criteria in a 44-year-old HIV-infected man is described. The search for cytomegalovirus, HBV and B19 parvovirus infections was negative. In situ hybridization did not reveal proviral HIV-1 DNA in a skin sample. A zidovudine-associated vasculitis was excluded. Corticosteroid therapy resolved vasculitis manifestations and was well tolerated without opportunistic infections during the 10-month follow-up period. An indirect pathogenetic role of HIV as a possible cause of vascular damage cannot be excluded in our patient.

Rehabilitation in joint and connective tissue diseases. 1. Systemic diseases

This self-directed learning module highlights new advances in this topic area. It is part of the chapter on rehabilitation in joint and connective tissue diseases in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses treatment and outcome in rheumatoid arthritis, musculoskeletal involvement in human immunodeficiency virus infection, scleroderma, systemic lupus erythematosus, and intraarticular injection of corticosteroids.

Bacterial infections: pyomyositis

Staphylococcal pyomyositis is an important and common condition in many areas in the tropics. The cause is probably multifactorial and includes damage to the skeletal muscle in the presence of staphylococcal bacteraemia, with or without depressed immunity. In Africa, there are indications of an increased prevalence in association with HIV infection in young adults in whom multiple and recurrent abscesses are common. Long bone osteomyelitis is an important differential diagnosis in these patients. Timely surgical drainage and antibiotics leads to resolution. Delayed diagnosis is associated with disseminated disease and septic cardiorespiratory complications.

Anaesthesia and rheumatoid arthritis

A review of the implications of rheumatoid arthritis on peri-operative anaesthetic management is presented. Pre-operative assessment should include a careful search for articular and systemic manifestations of the disease that may complicate intraoperative care. Drug disposition may vary from the normal patient as a result of changes in serum protein binding, together with possible exaggeration of pharmacodynamic responses. Airway management presents one of the greatest challenges to the anaesthetist, and care in manipulation of the cervical spine is paramount.

HIV-salivary gland disease. Salivary scintiscanning with technetium pertechnetate

The salivary disease in two patients with human immunodeficiency virus infection was investigated by technetium pertechnetate scintiscanning. Although there was good histologic evidence of benign lymphoepithelial disease, scintiscanning failed to delineate any salivary lesions. Technetium pertechnetate scintiscanning seems to be of little value in the detailed investigation of salivary disease in human immunodeficiency virus infection, though gallium scanning can help. Fine needle aspiration or biopsy remain the main diagnostic tools.

Pain in human immunodeficiency virus disease: a review

Pain is a symptom commonly experienced by people with HIV infection and its prevalence increases as the disease progresses. This article reviews the pathophysiology and clinical presentation of the various opportunistic infections, neoplasms and other HIV-related problems that may manifest as pain. The investigation of these conditions and their specific treatments, where available, are detailed. Because many of the conditions may be refractory to specific therapy, and the duration of investigations may be lengthy, symptomatic treatment should not be delayed. Guidelines are given on the symptomatic management of pain in these patients.

Arthropathy and HIV infection. A muddle of mimicry

Several rheumatic diseases are associated with human immunodeficiency virus (HIV) infection. The most common are reactive and psoriatic arthritis. Classic septic arthritis caused by Staphylococcus aureus and other common organisms is very rare: Instead, infectious arthritis caused by unusual organisms is the rule. Some of the HIV-related rheumatic syndromes behave like classic rheumatic diseases, while others may actually be new forms of disease. Often, one of the rheumatic syndromes is the presenting manifestation of underlying HIV infection. HIV-infected patients and patients with rheumatic disease often have similar laboratory abnormalities. Systemic lupus erythematosus, in particular, may be mistaken for HIV infection, in part because of cross-reactivity of antibodies. However, coexistence of systemic lupus erythematosus and rheumatoid arthritis with HIV infection is a rare occurrence. Traditional therapy for rheumatic diseases may not be indicated in HIV-infected patients and in fact may even be contraindicated.

Rheumatoid synovium is enriched in CD45RBdim mature memory T cells that are potent helpers for B cell differentiation

OBJECTIVE

To delineate the phenotype and function of synovial T cells in rheumatoid arthritis (RA).

METHODS

T cells from normal subjects or from RA peripheral blood (PB), synovial fluid (SF), or synovial tissue (ST) were analyzed phenotypically and functionally.

RESULTS

RA SF and ST T cells were found to be markedly enriched in CD45RAdim, CD45RO+, CD45RBdim mature memory cells, whereas in the PB, CD45RAbright naive T cells were more frequent than CD45RO+ memory T cells, and only a minority were CD45RBdim. SF and ST T cells proliferated less well and produced less interleukin-2 in response to mitogenic stimuli than did PB T cells. However, synovial T cells effectively promoted the production of Ig from normal B cells. Moreover, PB and synovial T cells differed in their capacity to down-regulate immunoglobulin production. Anti-CD3-stimulated PB T cells suppressed Ig production unless their proliferation was prevented with mitomycin C. In contrast, synovial T cells were potent helpers of B cell Ig production regardless of antecedent treatment with mitomycin C. To examine the relationship between the CD45RBdim phenotype and B cell help, CD45RBdim T cells were sorted from PB. As opposed to the findings with synovial T cells, suppression by control PB CD45RBdim T cells was observed, but only when large numbers were employed. B cell Ig production was enhanced after treatment of PB CD45RBdim T cells with mitomycin C. In contrast, healthy control sorted CD45RBbright or sorted CD4+, CD45RO+, CD45RBbright T cells did not support Ig secretion. After treatment with mitomycin C, both of these populations were more effective helpers of Ig production.

CONCLUSION

RA synovium is enriched in differentiated CD45RBdim memory T cells with potent helper activity and diminished capacity to down-regulate B cells, strongly implying an active role for these cells in the production of Ig in the synovium, and thus in the propagation of disease.

Pain syndromes in HIV infection

Pain causes considerable disability and discomfort in HIV (Human Immunodeficiency Virus) infected individuals. A large number of patients infected with HIV suffer from one or more pain-related syndromes. Pain is under-reported and suboptimally managed in these patients. An outline of the different pain syndromes, including headache, oral cavity pain, chest pain, abdominal pain, anorectal pain, musculoskeletal pain and peripheral neuropathic pain, and their aetiologies are discussed. Current pain management modalities, including non-narcotic and narcotic analgesics, tricyclic antidepressants, anticonvulsants, physical therapy and psychological techniques, are outlined. Treatment should be based on the same principles applied to the management of cancer-related pain. A multi-disciplinary, comprehensive approach to pain management will assist these individuals to achieve improved levels of comfort, function and quality of life in this ultimately terminal illness.

Potential role of the viral protease in human immunodeficiency virus type 1 associated pathogenesis

Infection with the human immunodeficiency virus type 1 (HIV-1) results in a variety of pathological changes culminating in the acquired immune deficiency syndrome (AIDS). While most of these changes can readily be accounted for either by direct effects of HIV-1 on the immune system or by indirect effects of secondary infectious agents as a result of faulty immune surveillance, the direct cause for a number of disease states, including some neuropathies, myopathies, nephropathy, thrombocytopenia, wasting syndromes and increased incidence of cancers (primarily lymphoma) has remained an enigma. We have recently shown that the HIV-1 protease, a viral encoded enzyme necessary for virus maturation and infectivity, can cleave a variety of host cell cytoskeletal proteins in vitro. Potential substrates for the HIV-1 protease are found in all of the cell types affected in these unexplained diseases. Recent proposals suggest that elements of the cytoskeleton may play an important role in the regulation of large scale genetic regulation. We propose that some of the degenerative changes associated with infection by HIV-1 are a direct consequence of cleavage of host cell cytoskeletal proteins, which in turn may be responsible for the increased incidence of cancer in HIV-1 infected individuals as a result of the perturbation of the regulation of gene expression by cytoskeletal components.

Musculoskeletal Manifestations of Human Immunodeficiency Virus Infection

Human immunodeficiency virus (HIV) causes an infection characterized by a wide spectrum of clinical manifestations, including musculoskeletal conditions that have been recognized with increasing frequency in recent years. Arthralgia, usually of moderate intensity, intermittent, and oligoarticular, is the most frequent rheumatic manifestation of HIV; it occurs in approximately 35% of the cases. Knees, shoulders, and elbows are the most frequently involved joints. A “painful articular syndrome,” characterized by severe articular or bone pain of short duration and absence of inflammation, can be observed in up to 10% of cases. Reiter's syndrome was the first rheumatological disorder recognized in association with HIV infection. The reported frequency has ranged from 0.5 to 9-9%. Most of the patients with this syndrome develop the incomplete form, and they usually are positive for human lymphocyte antigen B27. HIV-associated arthropathy has been observed by several groups. It is characterized by absence of recognizable rheumatic disease or syndrome, an oligoarticular pattern, and a subacute course. Psoriasis and psoriatic arthritis may flare up or develop in the course of an HIV infection and have been reported with increased prevalence in HIV patients. Psoriatic arthritis usually has a polyarticular and asymmetrical pattern. Several forms of myopathy have also been reported. Myalgia and a myopathy similar to polymyositis are the most frequent patterns observed. Two forms of the latter have been recognized, one attributed to HIV infection itself and the other to the use of zidovudine. Septic conditions in joint, bursa, bone, and muscle have rarely been described despite the immunodeficiency state. A Sjogren's syndrome-like disorder, termed “diffuse infiltrative lymphocyte syndrome,” may be seen in HIV patients, and it has many features that distinguish it from primary Sjögren's syndrome. Several types of vasculitis have been described; the necrotizing type is the most frequent type found. Fibromyalgia, hypertrophie osteo-arthropathy, and soft-tissue lesions have also been described. The pathogenetic mechanisms underlying the rheumatic manifestations of HIV infection are not well known. Their treatment is not well defined, but includes conventional antirheumatic therapy. Methotrexate and other immunosuppressive drugs should be used cautiously because they can precipitate the acquired immunodeficiency syndrome in an HIV-positive patient.

Nontropical pyomyositis as a cause of subacute, multifocal myalgia in the acquired immunodeficiency syndrome

We report a case of nontropical pyomyositis in a patient with acquired immunodeficiency syndrome and disseminated Mycobacterium avium infection, in which severe myalgia was the presenting symptom over several weeks. Multifocal muscle lesions were identified by gallium scanning and magnetic resonance imaging techniques. The epidemiology, possible pathogenesis, clinical features, diagnostic imaging, and therapy are reviewed. Early suspicion of nontropical pyomyositis in severely immunocompromised patients with "cryptic" myalgia is recommended.

A wider spectrum of spondyloarthropathies

As in other diseases of undetermined etiology, the diagnosis of ankylosing spondylitis (AS) and related spondyloarthropathies (SpA) is based on clinical and roentgenographic features. The current criteria for diagnosis of some of these diseases are too restricted, and do not recognize the existence of a much wider disease spectrum. For example, radiographically detected sacroiliitis is extremely frequent in AS, but may not be an obligate manifestation, especially in early or atypical forms of the disease. Arthritis involving the axial skeleton, including the sacroiliac joints, can be present in some patients without evidence of erosive disease roentgenographically. The disease spectrum of Reiter's syndrome has also been broadened considerably, and "incomplete" forms of Reiter's syndrome are observed much more commonly than the classical triad of arthritis, conjunctivitis, and urethritis. The term "B27-associated reactive arthritis" has been used in recent years to refer to SpA following enteric or urogenital infections, and the disease spectrum includes the clinical picture of typical Reiter's syndrome. The clinical spectrum of psoriatic SpA has been better clarified. Some of the less well defined B27-associated clinical syndromes include seronegative oligoarthritis, polyarthritis, or dactylitis ("sausagelike" toes) of the lower extremities, and heel pain caused by calcaneal (and tarsal) periostitis. These and other undifferentiated SpA have been ignored in previous epidemiological studies because of the inadequacy of the existing classification criteria. The European Spondylarthropathy Study Group (ESSG) has completed a study aimed at developing preliminary classification criteria for the whole group of SpA patients, with the specific intention of encompassing patients with undifferentiated SpA.