Osteoarticular manifestations associated with HIV infection

Map-Like Magnetic Resonance Imaging Changes in HIV-Positive Patient with Multiple Osteonecrosis: A Case Report

Background

Osteonecrosis is a common complication, particularly in HIV-infected patients undergoing long-term glucocorticoid therapy. This case report aims to highlight the unique "map-like" magnetic resonance imaging (MRI) changes observed in an HIV-positive patient with multiple osteonecrosis due to glucocorticoid overdose, emphasizing the importance of recognizing and managing this complication in this high-risk population.

Case Presentation

A 29-year-old HIV-positive male patient developed extensive multi-joint osteonecrosis involving 7 joint sites (right shoulder, bilateral hips, bilateral knees, and bilateral ankles) after 6 months of high-dose glucocorticoid treatment for an opportunistic pneumonia associated with his HIV status. The patient required prolonged glucocorticoid therapy to manage the severe lung infection. MRI revealed characteristic "map-like" changes, with the osteonecrotic areas distributed in a linear, clustered, or map-like pattern. To alleviate his condition and improve joint function, the patient underwent a customized treatment plan, including total hip replacement for the left hip, core decompression surgery for the right hip. Following surgical intervention, the patient experienced reduced joint pain and improved joint mobility.

Conclusion

This case underscores the potential risk of extensive multi-joint osteonecrosis in HIV-positive patients receiving long-term high-dose glucocorticoids, with the "map-like" MRI changes being a distinctive imaging feature. It emphasizes the importance of close monitoring and timely implementation of effective interventions in this high-risk population. Notably, core decompression surgery can improve local blood circulation, slow disease progression, and serve as an effective minimally invasive treatment option for early-stage osteonecrotic lesions.

Musculoskeletal manifestations of syphilis in adults: secondary syphilis presenting with ankle inflammatory arthritis and bone involvement with calvarial and sternal lesions. What the rheumatologist needs to know

Although the incidence of syphilis reached a historic low in 2000, the number of incident cases has since increased in men and women across the USA. In 2019, men who have sex with men (MSM) accounted for 57% of all primary and secondary (P&S) syphilis cases, and about half of MSM with P&S syphilis are living with human immunodeficiency virus (HIV) infection. Days after infection, Treponema pallidum disseminates and invades tissues distant from the site of inoculation. Once the spirochete disseminates, the host develops an inflammatory response; diagnosis requires a high level of suspicion since syphilis may affect the skin, musculoskeletal, cardiovascular, and central nervous systems. We report a 61-year-old man with virally suppressed HIV infection who presented with polyarthralgia, chest pain, and weight loss, diagnosed with secondary syphilis, manifesting with ankle inflammatory arthritis and bone involvement, of the calvarium and manubrium. Early and late syphilis in adults can manifest with articular and periarticular pathologies, including inflammatory arthritis, tenosynovitis, periostitis, and myositis. Higher clinical suspicion is needed for prompt diagnosis of syphilis in patients who are at risk and suspected of having an autoimmune disease. This report includes a review of the musculoskeletal manifestations of syphilis.

HIV-Positive Patients Are at Increased Risk of Venous Thromboembolism After Total Joint Replacement

BACKGROUND

Antiretroviral therapy has improved the life expectancy of HIV patients, leading to an increase in total joint replacement for age-related osteoarthritis. HIV patients are inherently hypercoagulable at baseline. The goal of our study was to compare the incidence of venous thromboembolism (VTE) in HIV patients with HIV-negative controls after total joint replacement.

METHODS

A multicenter, retrospective cohort study of 110 HIV patients (85 hips and 25 knees) and 240 HIV-negative controls (180 hips and 85 knees) between 2000 and 2018. Prophylactic anticoagulation was used in 98% of patients postoperatively-low-molecular weight heparin (73%), warfarin (19%), aspirin (6%), and clopidogrel (1%).

RESULTS

The VTE rate was 3.6% in the HIV-positive group (2.5% total hip arthroplasty [THA] and 8.0% total knee arthroplasty [TKA]) and 0.4% in the control group (0% THA and 1.7% TKA). VTEs occurred at the median (interquartile range) time of 40 days (1 to 52) post-op in the HIV group and 3 days post-op in the one control. Multivariable logistic regression adjusting for sex, smoking, history of VTE, and joint replaced identified HIV as an independent predictor of VTE (odds ratio 10.9, 95% confidence interval 1.1 to 114.0, P = 0.046). All patients with VTE were treated with warfarin (5 to 9 months); two cases were complicated by hemarthrosis and excessive bleeding at the insulin injection site.

CONCLUSION

We observed increased rates of symptomatic VTE in HIV patients after THA (2.5%) and TKA (8%) compared with HIV-negative control patients (0% and 1.7%, respectively). HIV positivity was identified as an independent predictor of perioperative VTE. Our data suggests that HIV patients may be at higher risk for post-op VTE than HIV-negative patients. Surgeons may want to consider the use of more potent anticoagulation (ie, warfarin or novel anticoagulants) for a longer duration in HIV-positive patients. However, further studies are necessary to form evidence-based guidelines regarding this practice.

LEVEL OF EVIDENCE

Level III, prognostic.

Assessing inflammation and its role in comorbidities among persons living with HIV

PURPOSE OF REVIEW

This article describes the use of biomarkers in expanding our understanding of chronic non-AIDS comorbidities among persons living with HIV (PLWH) receiving antiretroviral therapy (ART).

RECENT FINDINGS

We review current evidence that biomarkers of chronic immune activation and inflammation associate with a broad spectrum of end-organ diseases in PLWH. We discuss how ART may impact inflammation associated with HIV infection and the degree to which inflammation persists despite effective suppression of viral replication in plasma. We then discuss the limitations of the current literature, which lacks evidence of causality and disproportionately involves a few protein biomarkers that are unable to disentangle complex and overlapping biological pathways.

SUMMARY

Premature end-organ disease among PLWH has been repeatedly associated with higher levels of blood biomarkers reflecting inflammation and immune activation, which, despite viral suppression and CD4 T-cell increases after ART treatment, remain elevated relative to uninfected persons. There remain important unanswered questions with implications for the development of anti-inflammatory treatment strategies aimed at mitigating excess risk for end-organ comorbidities among PLWH.