Assessment and management of musculoskeletal disorders among patients living with HIV

Reactive Arthritis or HIV-Associated Arthropathy: Is It Important to Differentiate Them?

Although human immunodeficiency virus (HIV)-associated arthropathy is the most frequently described joint syndrome, the spectrum of its clinical manifestations is poorly known, and it is difficult to distinguish it from reactive arthritis (ReA). Knowing how to differentiate these two conditions has major implications regarding their prognosis and treatment. We present the case of an adult patient with a history of HIV infection with adequate virological control and good adherence to antiretroviral treatment, which began with an acute clinical picture consisting of additive asymmetric oligoarthritis with subsequent transition to symmetric polyarthritis predominantly in the upper extremities, initially attributed to ReA. Finally, his immunoserological profile was determined with negative results for rheumatoid factor, anti-citrulline antibodies, and human leukocyte antigen B27, achieving complete resolution of joint symptoms five weeks after treatment with nonsteroidal anti-inflammatory drugs, hydroxychloroquine, and intermediate doses of glucocorticoids, establishing the diagnosis of HIV-associated arthropathy.

HIV Symptom Clusters are Similar Using the Dimensions of Symptom Occurrence and Distress

CONTEXT

People living with HIV infection (PLWH) in the United States continue to experience a high symptom burden despite improvements in antiretroviral therapy.

OBJECTIVES

The purpose of this study was to determine if the number and types of symptom clusters differed based on whether symptom occurrence rates or distress ratings were used to create the clusters.

METHODS

Data from 2,000 patients with complete symptom occurrence rates and distress scores on the 20-item HIV Symptom Index from their first ambulatory clinic visit at one of six national HIV centers of excellence in the Center for AIDS Research Network of Integrated Clinical Systems were used in these analyses. Exploratory factor analysis was used to create the symptom clusters.

RESULTS

The same four symptom clusters (i.e., gastrointestinal, psychological, pain, body image) were identified using occurrence rates and distress ratings. For both dimensions of the symptom experience, the psychological, pain, and body image clusters each had the same symptoms. For the gastrointestinal cluster, four symptoms loaded on the occurrence dimension and six symptoms loaded on the distress dimension.

CONCLUSION

The number and types of symptom clusters were relatively similar across the occurrence and distress dimensions of the symptom experience. Symptom clusters in PLWH may provide insights into the development of targeted interventions for multiple co-occurring symptoms.

Neglected tropical rheumatic diseases

The complexities of dealing with rheumatic diseases in tropical countries are diverse and likely due to limited health care infrastructure, lack of diagnostic and therapeutic facilities, impact of dominant prevailing diseases, and the challenges of differentiating from infectious and non-infectious disease mimics. Several tropical diseases present with musculoskeletal and rheumatic manifestations and often pose a diagnostic dilemma to rheumatologists. The diagnosis is often delayed or the disease is misdiagnosed, leading to poor patient outcomes. Endemic tropical diseases like tuberculosis and leprosy have myriad rheumatic presentations and remain important differentials to consider in patients with rheumatic manifestations. Infection with human immunodeficiency virus is a great masquerade and can mimic manifestations of multiple diseases. The role of viral infections in triggering and perpetuating autoimmunity is well known and chikungunya arthritis is a classic example of the same. This review highlights the rheumatic manifestations of tropical diseases and aims to create awareness among the caregivers. Key Points • It is crucial to be aware and identify infectious diseases presenting with rheumatic manifestations in the tropics. • Presentations akin to classic rheumatic syndromes such as rheumatoid arthritis, spondyloarthritis, systemic lupus erythematosus and vasculitis are common.

Musculoskeletal Conditions in Persons Living with HIV/AIDS: A Scoping Review

OBJECTIVE

Globally 37.9 million people are living with HIV/AIDS, and with mortality rates declining, there is an increasing focus on comorbidities including musculoskeletal (MSK) disorders. Therefore, the aim of this scoping review was to generate and summarize an overview of the existing scientific literature dealing with MSK complaints in people living with HIV/AIDS (PLWHAs).

METHODS

This scoping review followed the five-stage methodological framework proposed by Arksey and O'Malley. We searched PubMed, EMBASE, CINAHL, and the Cochrane Library from inception to June 1, 2020. Two reviewers independently reviewed the articles for eligibility. A data extraction form was used to chart information such as author, year of publication, data source, sample size, country of origin, ethnicity, age, gender, antiretroviral therapy, MSK condition prevalence, and anatomical location.

RESULTS

The search identified 10 522 articles. Of these, 27 studies were included after full-text screening for data extraction. Studies were conducted in thirteen different countries with diverse data sources such as outpatient clinic files, hospital records, primary care clinic files, and AIDS Service Organization files. PLWHAs have a variety of MSK conditions. Most studies reported spinal pain such as lower back or neck pain, but pain in the extremities and osteoarthritis (OA) were also represented. However, the frequencies of pain at various anatomical sites were highly variable.

CONCLUSION

There is a lack of knowledge regarding MSK conditions in PLWHAs. Future studies designed to specifically study MSK complaints and disabilities are needed to gain a better picture of the impact of these conditions in PLWHAs and to inform prevention and treatment strategies globally in this often-underserved population.

People living with HIV and the emerging field of chronic pain-what is known about epidemiology, etiology, and management

PURPOSE OF REVIEW

Chronic pain is common in people living with HIV (PLWH). It causes significant disability and poor HIV outcomes. Despite this, little is understood about its etiology and management.

RECENT FINDINGS

Recent studies suggest that chronic pain in PLWH is caused by inflammation that persists despite viral load suppression. This coupled with central sensitization and psychosocial factors leads to chronic pain that is difficult to manage. PLWH with chronic pain often feel that their pain is incompletely treated, and yet there are few evidence-based options for the management of chronic pain in PLWH. Recent studies suggest that an approach pairing pharmacotherapy and nonpharmacologic therapy may address the complex nature of chronic in PLWH. Chronic pain in PLWH is common yet poorly understood. Further research is needed in order to better understand the etiology of chronic pain and its optimal management.

“I have failed to separate my HIV from this pain”: the challenge of managing chronic pain among people with HIV

Pain is a highly prevalent and burdensome symptom among people with HIV (PWH). This study aims to identify how the experience of living with HIV and chronic pain influences pain beliefs, health-seeking and pain management. Thirty-nine purposively sampled PWH with chronic pain (sample characteristics = 61% women, 79% Black, Asian and minority ethnic groups, 18% men who have sex with men, 45-54 median age category) participated in focus groups in London. Focus groups were co-facilitated with community members. Transcripts wereanalysed using a thematic approach. Findings revealed that HIV stigma, fractured care pathways, and general practitioners' lack of HIV training are barriers to supported pain management. Unaddressed pain results in poorer mental health and reduced quality of life, which has important clinical implications for HIV treatment adherence. Creating HIV-specific pain resources, activating social networks, and pain self-management techniques are potential solutions. Person-centred assessment and HIV training is needed to help clinicians identify PWH with chronic pain. Clear guidelines need to be developed to identify which health service providers are responsible for chronic pain management in PWH. This study generated a refined version of the Fear Avoidance Model that introduces a dimension of HIV-specific behaviours that impact PWHs seeking chronic pain management.

A Review of the Use of Biological Agents in Human Immunodeficiency Virus Positive Patients With Rheumatological Diseases

After approval, initial biologics etanercept, infliximab, and adalimumab became useful in the therapeutic armamentarium to treat rheumatoid arthritis (RA) patients who had an inadequate response to disease-modifying anti-rheumatic drugs (DMARDs). However, all phase-III clinical trials submitted to the FDA, by design, excluded patients who were human immunodeficiency virus (HIV) positive. They are another subset of patients with low immunity due to their HIV-positive status. Very little information is available about the use of biologics in this new group of patients if they fail to respond to DMARDS. The available literature is limited to case reports about HIV-positive RA patients with reported side effects. These side effects range from no opportunistic infections (OIs) in some to acute respiratory distress syndrome (ARDS) and disseminated intravascular coagulopathy (DIC) reported in others. Some HIV cases may initially present with rheumatological manifestations. With growing epidemiologic evidence of frequent joint manifestations in HIV-positive patients, HIV testing should be done more frequently in patients with RA, even those who deny risk factors for HIV. This review may help develop future guidelines on how to manage HIV-positive RA patients.

Rheumatological Manifestations in HIV-Positive Patients: A Single-Center Study

INTRODUCTION

Rheumatological manifestations (RM) are very common in human immunodeficiency virus (HIV)-infected patients. The aim of this study was to determine the clinical spectrum of musculoskeletal involvement and relationship with the Centers for Disease Control and Prevention (CDC) stage and CD4+ cells and other factors.

METHODS

A cross-sectional study was conducted involving 75 patients of over 18 years of either sex with confirmed HIV status attending a tertiary care hospital in north India in one calendar year. Baseline demographic details, relevant history including duration of combination antiretroviral therapy (cART), RM, joints involved, CD4 cell count, and biochemical parameters were evaluated.

RESULTS

Of 75 patients, 54 were male and 21 were female (mean age 33.15 ± 5.00 years, range 21-48 years). Most common RM was arthralgia (26.67%), followed by myalgia (18.67%), and arthritis (13.33%). Keratoderma blennorrhagicum (1.33%), tendo-achilles tendinitis (2.67%), and plantar fasciitis (2.67%) were other manifestations. Spondyloarthritis (SpA) was seen in 8% patients (undifferentiated SpA 4%, reactive arthritis 2.67%, psoriatic arthritis 1.67%). HIV-associated arthritis was seen in 2.67% while septic arthritis, rheumatoid arthritis, vasculitis, and diffuse infiltrative lymphocytic syndrome were seen in one patient (1.33%) each. The mean duration of disease in patients with RM was significantly less than patients without RM (p < 0.01). The erythrocyte sedimentation rate in patients with RM was significantly higher than in patients without RM (p < 0.05). Mean CD4 + cells were also significantly lower in patients with RM as compared to patients without RM (p < 0.05). Significantly fewer patients on cART had RM in comparison to patients not on cART (p < 0.001). Of 35 patients with RM,  25 were in CDC stage IV.

CONCLUSION

RM are common in HIV-infected patients. HIV arthralgia, myalgia, and undifferentiated SpA are the common manifestations. RM were associated with low CD4 counts. Most of the cases with RM were in CDC stage IV.

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.

The seroprevalence of HIV in patients undergoing lower limb Total Joint Arthroplasty (TJA) in South Africa

Aim: The aim was to assess the seroprevalence of Human Immunodeficiency Virus (HIV) in non-haemophilic patients undergoing primary Total Joint Arthroplasty (TJA) at an academic hospital in South Africa.

Methods: A retrospective review of all Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA) patients from January 2017 to December 2018 was conducted. All patients awaiting TJA were offered HIV screening and their demographic data were recorded. Consenting patients were tested or the refusal of testing was documented. The CD4+ T-cell count (CD4+) and viral load (VL) was measured for all HIV-positive patients and newly diagnosed patients were initiated on Highly Active Antiretroviral Treatment (HAART).

Results: We included 1007 patients in the study. The TJA population HIV seroprevalence was 10.7% (n = 108). The seroprevalence for THA was 14.9% (n = 78) and that for TKA was 6.2% (n = 30). There were 93 patients (9.2%) who refused screening. There were 12 (15.4%) and 3 patients (10%) that were newly diagnosed in the THA and TKA seropositive populations, respectively. The average CD4+ for THA and TKA was 569 cells/mm³ (105–1320) and 691 cells/mm³ (98–1406), respectively. The VL was undetectable in 75.9% (n = 82) of HIV-positive patients. Overall 12 HIV-positive patients (11.12%) had CD4+ <200 cells/mm³, 8 of these patients (66%) were newly diagnosed. The average age of the seropositive population was 58 ± 6.5 years and 66 ± 8.5 years for THA and TKA, respectively (p = 0.03). Femoral head osteonecrosis was the underlying pathology for 65.38% (n = 51) of seropositive patients for THA.

Conclusion: The seroprevalence of HIV in patients undergoing THA in our South African institution is greater than the seroprevalence in the general population. The seroprevalence of HIV in THA is significantly greater than that in TKA. This may reflect the association between HIV, HAART and hip joint degeneration. Our findings draw attention to the significant burden HIV has on TJA.

Impact of musculoskeletal symptoms on physical functioning and quality of life among treated people with HIV in high and low resource settings: A case study of the UK and Zambia

Background

Musculoskeletal symptoms in people living with HIV (PLWH) such as pain, joint stiffness, and fatigue are commonly reported. Prevalence rates of up to 45%, 79% and 88% respectively have been reported. However, very little is known about differences in prevalence and impact of musculoskeletal symptoms on physical functioning and quality of life of PLWH on effective combined antiretroviral treatment (cART) in high and low-resource settings.

Methods

A cross-sectional study of PLWH on effective cART enrolled from two large urban clinics in the UK and Zambia was conducted in 2016. Eligible participants had no history of trauma to the joints within 4 weeks of recruitment, or documented evidence of previous rheumatic disease. Current musculoskeletal symptoms, functional ability, and health-related quality of life were evaluated using the health assessment (HAQ) and quality-of-life short form (SF-36) self-reported questionnaires.

Results

214 patients were enrolled (108:UK and 106:Zambia). Participants from Zambia were younger (47 vs 44 years) and had significantly lower CD4 counts (640 vs 439 cells/mL p = 0.018) compared to those from the UK, while the UK group had lived with HIV longer (11 vs 6 years; p<0.001) and reported more comorbidities than the Zambian group (66% vs 26%; p<0.001). Musculoskeletal pain was common in both groups (UK:69% vs Zambia:61% p = 0.263) but no significant differences in physical functional capacity between the groups were observed. However, the UK group had significantly worse quality of life measurements (general health, vitality, mental health, emotional, and social functioning) associated with musculoskeletal symptoms compared to the Zambian group (p<0.001).

Conclusions

Musculoskeletal symptoms in PLWH from both the UK and Zambia were common. PLWH in the UK reported worse quality of life measures associated with musculoskeletal symptoms compared to those in Zambia, suggesting that factors such as mental health, patient expectations and multimorbidity might play a role in determining well-being and quality of life of PLWH with musculoskeletal symptoms.

Establishment and characterisation of a stavudine (d4T)-induced rat model of antiretroviral toxic neuropathy (ATN) using behavioural and pharmacological methods

Human immuno-deficiency virus (HIV) associated sensory neuropathy (SN) is a frequent complication of HIV infection. It is extremely difficult to alleviate and hence the quality of life of affected individuals is severely and adversely impacted. Stavudine (d4T) is an antiretroviral drug that was widely used globally prior to 2010 and that is still used today in resource-limited settings. Its low cost and relatively good efficacy when included in antiretroviral dosing regimens means that there is a large population of patients with d4T-induced antiretroviral toxic neuropathy (ATN). As there are no FDA approved drugs for alleviating ATN, it is important to establish rodent models to probe the pathobiology and to identify potentially efficacious new drug treatments. In the model establishment phase, d4T administered intravenously at a cumulative dose of 375 mg/kg in male Wistar Han rats evoked temporal development of sustained mechanical allodynia in the hindpaws from day 10 to day 30 after initiation of d4T treatment. As this d4T dosing regimen was also well tolerated, it was used for ATN model induction for subsequent pharmacological profiling. Both gabapentin at 30-100 mg/kg and morphine at 0.3-2 mg/kg given subcutaneously produced dose-dependent relief of mechanical allodynia with estimated ED₅₀'s of 19 mg/kg and 0.4 mg/kg, respectively. In contrast, intraperitoneal administration of meloxicam or amitriptyline up to 30 mg/kg and 7 mg/kg, respectively, lacked efficacy. Our rat model of ATN is suitable for investigation of the pathophysiology of d4T-induced SN as well as for profiling novel molecules from analgesic drug discovery programs.

Exogenous steroid-induced hypoadrenalism in a person living with HIV caused by a drug-drug interaction between cobicistat and intrabursal triamcinolone

We report a diagnosis of exogenous steroid-induced hypoadrenalism in a person living with HIV caused by a drug-drug interaction (DDI) between intrabursal triamcinolone and the pharmacokinetic booster cobicistat. A 53-year-old woman living with HIV, managed with dolutegravir and cobicistat-boosted darunavir, presented to the orthopaedic clinic with worsening hip pain. She was diagnosed with greater trochanteric pain syndrome (GTPS) of the hip and was treated with intrabursal injection of bupivacaine and triamcinolone. Seven days following this injection, she presented with Cushingoid features, an undetectable cortisol and was diagnosed with exogenous steroid-induced hypoadrenalism. Cobicistat is a cytochrome P450 3A inhibitor and in this case inhibited clearance of intrabursal triamcinolone, leading to exogenous glucocorticoid excess and adrenal suppression. This is the first report to describe this predictable DDI with cobicistat following intrabursal glucocorticoid injection. This case highlights the complexities in managing non-HIV-related chronic morbidities in people living with HIV.