The diffuse infiltrative lymphocytosis syndrome (DILS). A comprehensive review

Blood-borne viruses and neurological manifestations: An overview

Infections caused by blood-borne viruses, such as human immunodeficiency virus (HIV), human T-lymphotropic virus (HTLV), hepatitis C virus (HCV), and hepatitis B virus (HBV), are systemic diseases that can lead to a wide range of pathological manifestations. Besides causing severe immune and hepatic disorders, these viral pathogens can also induce neurological dysfunctions via both direct and indirect mechanisms. Neurological dysfunctions are one of the most common manifestations caused by these viruses that can also serve as indicators of their infection, impacting the clinical presentation of the disease. The main neurological manifestations of these blood-borne viral pathogens consist of several central and peripheral nervous system (CNS and PNS, respectively) dysfunctions. The most common neurological manifestations of HIV, HTLV, HCV, and HBV include HIV-associated peripheral neuropathy (PN), HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP), and HCV-/HBV-associated PN, respectively. Nonetheless, patients infected with these viruses may experience other neurological disorders, either associated with these conditions or manifesting in isolation, which can often go unnoticed or undiagnosed by physicians. The present review aims to provide an overview of the latest evidence on the relationship between blood-borne viruses and neurological disorders to highlight neurological conditions that may be somewhat overlooked by mainstream literature and physicians.

HIV-Associated Rheumatic Diseases: A Narrative Review

ABSTRACT

Human immunodeficiency virus (HIV) is widely prevalent among the world population. Although, historically, it has been linked to opportunistic infections in keeping with immunodeficiency and immune dysregulation, it has also been associated with a wide variety of autoimmune manifestations. With the introduction of highly active antiretroviral therapy and subsequent restoration of immunity, there have been multiple immune-mediated diseases that have resurfaced in the HIV population. Our review highlights autoimmune diseases in association with HIV and its targeted therapies in detail.

Infectious Neuropathies

OBJECTIVE

This article discusses the clinical manifestations and management of infectious peripheral neuropathies.

LATEST DEVELOPMENTS

Several infectious etiologies of peripheral neuropathy are well-recognized and their treatments are firmly established. The COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is associated with several central and peripheral nervous system manifestations, including peripheral neuropathies. Additionally, some COVID-19 vaccines have been associated with Guillain-Barré syndrome. These disorders are an active area of surveillance and research. Recent evidence-based guidelines have provided updated recommendations for the diagnosis and treatment of Lyme disease.

ESSENTIAL POINTS

Infectious agents of many types (primarily bacteria and viruses) can affect the peripheral nerves, resulting in various clinical syndromes such as mononeuropathy or mononeuropathy multiplex, distal symmetric polyneuropathy, radiculopathy, inflammatory demyelinating polyradiculoneuropathy, and motor neuronopathy. Knowledge of these infections and the spectrum of peripheral nervous system disorders associated with them is essential because many have curative treatments. Furthermore, understanding the neuropathic presentations of these disorders may assist in diagnosing the underlying infection.

An Overview of the Dry Eye Disease in Sjögren's Syndrome Using Our Current Molecular Understanding

Sjögren's syndrome is a chronic and insidious auto-immune disease characterized by lymphocyte infiltration of exocrine glands. The patients typically present with ocular surface diseases related to dry eye and other systemic manifestations. However, due to the high prevalence of dry eye disease and the lack of objective and clinically reliable diagnostic tools, discriminating Sjögren's syndrome dry eye (SSDE) from non-Sjögren's syndrome dry eye (NSSDE) remains a challenge for clinicians. Diagnosing SS is important to improve the quality of life of patients through timely referral for systemic workups, as SS is associated with serious systemic complications such as lymphoma and other autoimmune diseases. The purpose of this article is to describe the current molecular understanding of Sjögren's syndrome and its implications for novel diagnostic modalities on the horizon. A literature review of the pre-clinical and clinical studies published between 2016 and 2022 was conducted. The SSDE pathophysiology and immunology pathways have become better understood in recent years. Novel diagnostic modalities, such as tear and saliva proteomics as well as exosomal biomarkers, provide hope on the horizon.

Virus-Associated Nephropathies: A Narrative Review

While most viral infections cause mild symptoms and a spontaneous favorable resolution, some can lead to severe or protracted manifestations, specifically in immunocompromised hosts. Kidney injuries related to viral infections may have multiple causes related to the infection severity, drug toxicity or direct or indirect viral-associated nephropathy. We review here the described virus-associated nephropathies in order to guide diagnosis strategies and treatments in cases of acute kidney injury (AKI) occurring concomitantly with a viral infection. The occurrence of virus-associated nephropathy depends on multiple factors: the local epidemiology of the virus, its ability to infect renal cells and the patient's underlying immune response, which varies with the state of immunosuppression. Clear comprehension of pathophysiological mechanisms associated with a summary of described direct and indirect injuries should help physicians to diagnose and treat viral associated nephropathies.

The role of virus infections in Sjögren’s syndrome

Primary Sjögren’s syndrome (pSS) is an autoimmune disease with a clinical picture of not only mainly exocrine gland involvement, with dryness symptoms, but also internal organ and systems involvement. The epithelial damage and releasing of antigens, which, in some circumstances, become autoantigens, underlay the pathogenesis of pSS. The activation of autoimmune processes in pSS leads to the hyperactivation of B cells with autoantibody production and other immunological phenomena such as hypergammaglobulinemia, production of cryoglobulins, or formation of extra-nodal lymphoid tissue. Among the risk factors for the development of this disease are viral infections, which themselves can activate autoimmune reactions and influence the host’s immune response. It is known that viruses, through various mechanisms, can influence the immune system and initiate autoimmune reactions. These mechanisms include molecular mimicry, bystander activation, production of superantigens—proteins encoded by viruses—or a programming to produce viral cytokines similar to host cytokines such as, e.g., interleukin-10. Of particular importance for pSS are viruses which not only, as expected, activate the interferon pathway but also play a particular role, directly or indirectly, in B cell activation or present tropism to organs also targeted in the course of pSS. This article is an attempt to present the current knowledge of the influence specific viruses have on the development and course of pSS.

Multilocular Thymic Cyst in a Patient with Untreated HIV/AIDS: Case Report and Review of the Literature

BACKGROUND

Multilocular thymic cysts (MTCs) in adults with human immunodeficiency virus (HIV) are rarely reported.

CASE PRESENTATION

We describe a case of symptomatic MTC in a male with untreated HIV. A presumptive diagnosis was established based on radiographic imaging and biopsy. Pathologic diagnosis and exclusion of malignancy were ultimately confirmed the following thymectomy. In conjunction with starting antiretroviral therapy, the patient recovered well post-operatively with a resolution of his presenting symptoms.

CONCLUSION

Our case report and review of the literature serve to highlight MTCs as an important clinical entity occurring in persons with HIV.

[Efficacy of highly active antiretroviral therapy alone in the treatment of diffuse lymphocytic infiltration syndrome in an ivorian patient living with HIV: a case report]

Objective

We report in this work the efficacy of highly active antiretrovirals (ARVs) alone in the treatment of diffuse infiltrative lymphocytosis syndrome (DILS) without the use of corticosteroids, which appears risky in patients living with HIV.

Observation

This is a 60-year-old HIV-positive patient, discovered during the etiological workup of renal failure, which revealed a non-nephrotic glomerular profile. The renal biopsy found an interstitial infiltrate of CD8 suggestive of DILS. Management consisted in starting ARV treatment alone (lamuvidine, abacavir and raltegravir) without associated corticosteroid therapy. The clinical evolution under treatment was marked by a recovery of the renal function with a creatininemia at 99 μmol/l, a regression of the proteinuria, a CD4 rate at 293/mm³ and an HIV viral load at 533.3 copies or 1.6 log in the space of 3 months.

Conclusion

DILS is a diffuse systemic disease in HIV patients who are usually under poor virological control. In view of the strong immunosuppression and the absence of other infiltrative diseases, it appeared to us to be risky and unjustified to add a corticosteroid therapy.

Neurologic Complications of Human Immunodeficiency Virus

PURPOSE OF REVIEW

This article reviews the neurologic complications associated with human immunodeficiency virus (HIV) infection.

RECENT FINDINGS

Neurologic complications of HIV may be caused by direct virally mediated pathology, immune-mediated phenomena in response to viral infection, or opportunistic infections secondary to depletion of lymphocytes. These neurologic disorders may be influenced by the degree of immunosuppression (ie, CD4+ T-cell lymphocyte count) and stage of infection (early versus late), as well as use of antiretroviral therapy, and may manifest as a variety of central and peripheral neurologic syndromes, including the more commonly encountered HIV-associated cognitive disorders and length-dependent sensorimotor polyneuropathy, respectively. Immune dysregulation underlies the majority of these neurologic phenomena, as well as other HIV-associated conditions including immune reconstitution inflammatory syndrome (IRIS), CD8 lymphocytosis, and potentially the development of compartmentalized infection within the CSF, also referred to as CSF escape.

SUMMARY

This article reviews a spectrum of clinical syndromes and related neuropathologic states associated with HIV infection.

HIV Neuropathy-Associated Foot Drop, a Presenting Sign of HIV Infection, Resolving After Initiation of Antiretroviral Therapy: A Clinical Vignette

ABSTRACT

Peripheral neuropathy is one of the most frequent complaints in patients with HIV. Many complex syndromes exist, with the etiology being secondary to the disease process itself, antiretroviral medication, or immune reconstitution. However, isolated mononeuropathy is rare. In this case, we present a previously healthy man who complained of several months of worsening right foot drop that did not improve with physical therapy or lifestyle interventions. He had begun to use an solid ankle-foot orthotic on this right lower limb to minimize tripping and prevent falls. He had no other neuromuscular involvement or constitutional complaints. Nerve conduction study of the right lower limb showed decreased peak amplitude, prolonged distal latency, and decreased conduction velocity of the deep peroneal nerve. Electromyography revealed abnormal insertional activity and absent motor unit action potentials in both the right tibialis anterior and right extensor digitorum brevis muscles. Magnetic resonance imaging of the right lower limb was suggestive of acute/subacute denervation of the right tibialis anterior muscle. An extensive laboratory workup revealed active HIV infection with a significant viral load. Once the diagnosis was made, the patient was started on antiretroviral treatment. Six months later, his foot drop had entirely resolved, in association with significant improvements in viral load and CD4 count. He has since been ambulating without assistive devices and his HIV/AIDS disease process remains well controlled. This clinical vignette is the first, to our knowledge, to illustrate that an acute focal mononeuropathy causing foot drop and gait dysfunction in an otherwise healthy-appearing individual can be a heralding sign of HIV/AIDS. Furthermore, it also suggests that this functional deficit can be reversed with timely initiation of antiretroviral treatment. Early recognition, diagnosis, and treatment in this patient have not only led to an uncomplicated AIDS disease course but also restored his ability to ambulate with complete independence and improved his quality of life.

Benign lymphoproliferative disorders in the immunosuppressed patient: an update

Immunosuppressed patients may be affected by a wide range of lymphoproliferative disorders (LPDs) ranging from self-limiting disorders to malignant lymphoid proliferations. These LPDs may be associated with systemic immune disorders, develop following organ transplantation or occur in the background of other forms of iatrogenic immunosuppression. Lymphotropic viruses, including Epstein-Barr virus (EBV) and human herpesvirus-8 (HHV8), have been associated with the pathogenesis of distinct LPDs. The resulting classification of this group of disorders is very complex and inconsistent, with several new and emerging entities. Consequently, the diagnosis of an LPD, especially in an immunosuppressed patient, and its subsequent clinical management usually represent an important pitfall in daily clinical and pathology work. Therefore, the aim of this review was to use the available literature to describe the clinicopathological features of the most important benign LPDs that may be diagnosed in the head and neck region of immunosuppressed patients. Original clinical and microscopic images were used to illustrate some of these entities.

HIV Lymphadenopathy: Differential Diagnosis and Important Imaging Features

OBJECTIVE. The purpose of this article is to review important imaging and clinical features to help elucidate causes of lymphadenopathy in patients with HIV infection. CONCLUSION. HIV lymphadenopathy has various causes generally categorized as inflammatory or reactive, such as immune reconstitution syndrome; infectious, such as tuberculous and nontuberculous mycobacterial infections and HIV infection itself; and neoplastic, such as lymphoma, Kaposi sarcoma, and Castleman disease. It is important to consider patients' demographic characteristics, clinical presentations, CD4 lymphocyte counts, and radiologic features to identify likely causes of lymphadenopathy.

Interplay between oral immunity in HIV and the microbiome

This Basic Science Workshop addressed the oral microbiome. At the 7th World Workshop on Oral Health & Disease in HIV/AIDS in India in 2014, some aspects of the human microbiome were discussed, and research questions formulated. Since that time, there have been major advances in technology, which have stimulated a number of publications on many aspects of the human microbiome, including the oral cavity. This workshop aimed to summarize current understanding of the "normal" microbiome of the oral cavity compared to that during HIV infection, and how oral immune factors and other clinical variables alter or control the oral microbiome. An important question is whether successful treatment with anti-retroviral therapy, which leads to a significant drop in viral loads and immune reconstitution, is associated with any change or recovery of the oral microbiome. Additionally, the workshop addressed the issue of which parameters are most appropriate/correct to evaluate the oral microbiome and how clinically relevant are shifts/changes in the oral microbiome. The workshop evaluated current knowledge in five research areas related to five basic questions and identified further topics where further research is required.

Sicca syndrome following immune checkpoint inhibition

The recent approval of Immunologic checkpoint inhibitors as an effective therapeutic strategy against cancer came at the cost of toxicities mediated by an excessive activation of immune system against health tissues, including among others musculoskeletal and sicca complaints.The latter occur in the context of an entity reminiscent of Sjogren's syndrome, with distinct characteristics such as abrupt onset, male predominance, lower prevalence of autoantibodies and response to steroids.

Role of Viral Infections in the Pathogenesis of Sjögren's Syndrome: Different Characteristics of Epstein-Barr Virus and HTLV-1

Viruses are possible pathogenic agents in several autoimmune diseases. Sjögren’s syndrome (SS), which involves exocrine dysfunction and the appearance of autoantibodies, shows salivary gland- and lacrimal gland-oriented clinical features. Epstein-Barr virus (EBV) is the most investigated pathogen as a candidate that directly induces the phenotype found in SS. The reactivation of the virus with various stimuli induced a dysregulated form of EBV that has the potential to infect SS-specific B cells and plasma cells that are closely associated with the function of an ectopic lymphoid structure that contains a germinal center (GC) in the salivary glands of individuals with SS. The involvement of human T-cell leukemia virus type 1 (HTLV-1) in SS has been epidemiologically established, but the disease concept of HTLV-1-associated SS remains unexplained due to limited evidence from basic research. Unlike the cell-to-cell contact between lymphocytes, biofilm-like structures are candidates as the mode of HTLV-1 infection of salivary gland epithelial cells (SGECs). HTLV-1 can infect SGECs with enhanced levels of inflammatory cytokines and chemokines that are secreted from SGECs. Regardless of the different targets that viruses have with respect to affinitive lymphocytes, viruses are involved in the formation of pathological alterations with immunological modifications in SS.

Human immunodeficiency virus infection (HIV)-associated rheumatic manifestations in thepre- and post-HAART eras

Rheumatic manifestations remain an important clinical manifestation associated to HIV. To date after 4 decades of the onset of the HIV/AIDS pandemic, almost 37 million individuals are living with the infection, including close to 2 million of newly infected individuals. The status, however, 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 renal cardiovascular, diabetes, malignancy, and autoimmune co-morbid disorders have become prevalent and relevant. In addition, the spectrum of rheumatic disorders also has changed since the introduction of HAART and its diagnosis and treatment represents a challenge. The purpose of this review is to define and discuss the HIV-related rheumatic manifestations in the pre- and post-HAART eras.

Common oral opportunistic infections in Human Immunodeficiency Virus infection/Acquired Immunodeficiency Syndrome: Changing epidemiology; diagnostic criteria and methods; management protocols

There were 36.9 million in the world living with human immunodeficiency virus (HIV) infection/acquired immunodeficiency syndrome (AIDS) as of 2017, and new infections have seen a reduction by 18% since 2010. But this rate of decline is not sufficient for the goal of eradication of AIDS by 2030. Only 21.7  million people infected with HIV have accesses to antiretroviral therapy, with the rest at risk of the potential complications of HIV infection. It has been shown that oral lesions are diagnostic and prognostic of HIV infection, and many oral opportunistic infections continue to be a major problem, particularly in developing countries. It is therefore important that dental surgeons be aware and updated to recognize and manage the oral effects of HIV infection/AIDS. This chapter describes the classification, diagnosis, and management of oral lesions in these patients, based on our current understanding of the infection. This review also discusses the standardization of diagnosis of oral lesions in HIV infection/AIDS patients, immune reconstitution inflammatory syndrome case definition, and the research priorities formulated at the 7th World Workshop on Oral Health and Disease in AIDS.

Risk of Diffuse Infiltrative Lymphocytosis Syndrome in HIV-Infected Patients: A Nationwide Population-Based Cohort Study

OBJECTIVE

Diffuse infiltrative lymphocytosis syndrome (DILS) is the term used for sicca syndrome in HIV patients and has similar clinical manifestations as Sjögren syndrome. In this nationwide population-based study, we aimed to determine the association between HIV infection and DILS in the Taiwanese population.

METHODS

The National Health Insurance Research Database was searched for cases of DILS in HIV-infected individuals diagnosed between January 1, 2000, and December 31, 2012. The incidence of DILS and the factors associated with DILS in people living with HIV/AIDS (PLWHA) were determined.

RESULTS

A total of 20,364 PLWHA were followed, and 57 (0.28%) individuals had new-onset DILS. The incidence rate of DILS in PLWHA was 0.56/1000 person-years. One (0.11%) female HIV patient with highly active antiretroviral therapy (HAART) and 24 (2.99%) without HAART had incident DILS, whereas 22 (0.17%) male HIV patients with HAART and 10 (0.17%) without HAART had incident DILS. Hypertension increased the risk of incident DILS. HAART decreased the risk of DILS, but this relationship somewhat attenuated in an adjusted model. None of the patients taking emtricitabine, raltegravir, darunavir, enfuvirtide, or tipranavir developed DILS. Lopinavir was associated with a decreased risk of DILS (adjusted hazard ratio = 0.10, 95% confidence interval: 0.01 to 0.84), whereas zalcitabine was associated with an increased risk of DILS (adjusted hazard ratio = 13.7, 95% confidence interval: 2.18 to 85.9).

CONCLUSIONS

DILS is a rare disease found in PLWHA. Hypertension is a risk factor for incident DILS, and HAART could affect the pathogenesis of DILS. Zalcitabine was the only antiretroviral agent found to increase the risk of DILS.

Chronic Benign CD8+ Proliferation: A Rare Affection that Can Mimic a Lymphoma Relapse

Chronic benign CD8+ proliferation is a rare syndrome that can take the form of a variety of other diseases. Peripheral adenopathy, cytopenia, and infiltration of the liver, kidneys, bowels, or other organs are the most common clinical presentations of the syndrome. CD8+ expansion can be clonal and nonclonal. It generally occurs in patients with innate or acquired immunodeficiency (HIV+) or in patients receiving immunosuppressive therapy. It has been found repeatedly in patients who developed severe hypogammaglobulinemia after treatment with rituximab. Diagnosis of the disease can be difficult because it can mimic relapse of a lymphoma, and a common biopsy examination cannot identify the problem at first. The authors describe a case of a patient pretreated with rituximab who developed agammaglobulinemia and peripheral adenopathy. Biopsy of an enlarged lymph node showed "reactive lymphadenitis." Additionally, a flow-cytometric examination revealed a pathological population of CD8+ lymphocytes. The treatment, which differed from treatments of lymphoma relapse, consisted of corticosteroids and IVIG substitutions and has led to a regression of clinical symptoms. With more frequent usage of rituximab, one can expect increased occurrence of a very rare CD8+ expansion that can reliably emulate the relapse of a lymphoma.

Human immunodeficiency virus and salivary gland pathology: an update

Salivary gland disease is a common manifestation of human immunodeficiency virus (HIV) infection, with a significant increase in prevalence over the last two decades. This review summarizes contemporary knowledge of non-neoplastic salivary gland disease in HIV infection. The aim is to update information on and bring attention to those lesions, which are almost exclusive to the salivary glands in the HIV setting. The associated conditions include xerostomia or salivary gland hypofunction; Sjögren syndrome-like illness; salivary gland enlargements, including benign lymphoepithelial cysts (cystic lymphoid hyperplasia); diffuse infiltrative CD8+ lymphocytosis syndrome; and mucous extravasation phenomena, especially ranula. Many of these conditions show considerable overlap, and thus, the term HIV-associated salivary gland disease is used to designate HIV infection with xerostomia or salivary gland hypofunction, enlargement of one or more of the major salivary glands, or both. These manifestations may be related to HIV infection, and therefore, prompt recognition is invaluable in the diagnosis and treatment of both the salivary gland disease and HIV 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.

Contribution of HIV Infection, AIDS, and Antiretroviral Therapy to Exocrine Pathogenesis in Salivary and Lacrimal Glands

The structure and function of exocrine glands are negatively affected by human immunodeficiency virus (HIV) infection and its co-morbidities, including innate and adaptive immune responses. At the same time, exocrine function may also be influenced by pharmacotherapies directed at the infectious agents. Here, we briefly review the role of the salivary glands and lacrimal glands in normal physiology and exocrine pathogenesis within the context of HIV infection and acquired immune deficiency syndrome (AIDS), including the contribution of antiretroviral therapies on both. Subsequently, we discuss the impact of HIV infection and the types of antiretroviral therapy on disease management and therapy development efforts.

Neuromuscular diseases associated with Human Immunodeficiency Virus infection

From the most common distal symmetric polyneuropathy (Bilgrami and O'Keefe, 2014) to the rare motor neuron diseases, HIV infection is associated with pathology at all levels of the peripheral nervous system. HIV infection can cause these conditions due to viral exposure itself, the resulting immune dysregulation, opportunistic infections found in untreated patients, and from the therapy used in treatment of the virus. Before the advent of antiretroviral therapy, 5 neuromuscular diseases associated with HIV often resulted from opportunistic infections. With advances in antiretroviral therapy, the etiologies of neuromuscular complications more frequently become the result of prolonged HIV exposure, comorbid diseases, and side effects of medications. In this article we review the literature on HIV associated neuromuscular diseases, emphasizing the more recent studies in the post antiretroviral era, but also reviewing conditions more prevalent in the pre antiretroviral era which continue to be seen in developing countries and resource poor areas. This discussion includes the following conditions: distal symmetric polyneuropathy, autonomic neuropathy, inflammatory demyelinating polyneuropathy, mononeuropathy, mononeuropathy multiplex, polyradiculopathies, myelopathy, myopathy, motor neuron disease, and antiretroviral treatment related conditions.

HIV neuropathology

Primary human immunodeficiency virus (HIV) neuropathologies can affect all levels of the neuraxis and occur in all stages of natural history disease. Some, like HIV encephalitis, HIV myelitis, and diffuse infiltrative lymphocytosis of peripheral nerve, reflect productive infection of the nervous system; others, like vacuolar myelopathy, distal symmetric polyneuropathy, and central and peripheral nervous system demyelination, are not clearly related to regional viral replication, and reflect more complex cascades of dysregulated host immunity and metabolic dysfunction. In pediatric patients, the spectrum of neuropathology is altered by the impacts of HIV on a developing nervous system, with microcephaly, abundant brain mineralization, and corticospinal tract degeneration as examples of this unique interaction. With efficacious therapies, CD8 T-cell encephalitis is emerging as a significant entity; often this is clinically recognized as immune reconstitution inflammatory syndrome, but has also been described in the context of viral escape and treatment interruption. The relationship of HIV neuropathology to clinical symptoms is sometimes straightforward, and sometimes mysterious, as individuals can manifest significant deficits in the absence of discrete lesions. However, at all stages of the natural history disease, neuroinflammation is abundant, and critical to the generation of clinical abnormality. Neuropathologic and neurobiologic investigations will be central to understanding HIV nervous system disorders in the era of efficacious therapies.

Assessment and management of musculoskeletal disorders among patients living with HIV

HIV is a global pandemic. However, anti-retroviral therapy has transformed the prognosis and, providing compliance is good, a normal life expectancy can be anticipated. This has led to increasing numbers of people with chronic prevalent, treated infection living to older ages. Musculoskeletal pain is commonly reported by HIV patients and, with resumption of near-normal immune function, HIV-infected patients develop inflammatory rheumatic diseases that require assessment and management in rheumatology clinics. Moreover, it is becoming apparent that avascular necrosis and osteoporosis are common comorbidities of HIV. This review will contextualize the prevalence of musculoskeletal symptoms in HIV, informed by data from a UK-based clinic, and will discuss the management of active inflammatory rheumatic diseases among HIV-infected patients taking anti-retroviral therapy, highlighting known drug interactions.

Orofacial manifestations in patients with inflammatory rheumatic diseases

The main orofacial manifestation of the inflammatory rheumatic diseases is that of Sjögren's syndrome. In addition, there is a constellation of orofacial manifestations of the inflammatory rheumatic diseases, many of which are extra-articular with some constituting presenting signs of the underlying rheumatic disease. This review will discuss the orofacial manifestations in a variety of connective tissue diseases and will also allude to the oral adverse drug reactions that may occur as a consequence of therapy.

A pathologically proven case of adult-onset HIV-related lymphocytic interstitial pneumonia with acute exacerbation treated with steroid and antiretroviral therapy

Lymphocytic interstitial pneumonia (LIP) is a rare opportunistic illness in human immunodeficiency virus (HIV)-infected adults, although it is relatively common among HIV-infected children. Most adult cases have been reported in African and Afro-Caribbean patients and few cases have been reported from Asia. Acute exacerbation of HIV-related LIP has not been well described. Here we report a pathologically proven case of acute exacerbation of adult-onset HIV-related LIP. The patient was an African immigrant living in Japan who presented with chronic dyspnea and diffuse bilateral pulmonary infiltrates. His clinical, radiological, and pathological findings were consistent with those of LIP. After a diagnostic surgical lung biopsy, his hypoxemia and pulmonary infiltrates exacerbated rapidly over a few days, although his condition had not progressed during the previous year. LIP may be an important differential diagnosis among adult patients in Asian countries, especially patients of non-Asian ethnicity.