Human immunodeficiency virus associated spondyloarthropathy: pathogenic insights based on imaging findings and response to highly active antiretroviral treatment

Case report of HIV associated arthritis

Human immunodeficiency virus (HIV) infection is prevalent worldwide. Children living with HIV/AIDS form a vulnerable subsection and may frequently present with clinical symptoms in the first year of life itself. Besides its well-known signs and symptoms, HIV infection can have a wide spectrum of musculoskeletal manifestations. We report a case of a child with HIV infection with arthritis as a predominant presentation. The patient was anemic (Hb: 2.6 g/dl) and had features suggestive of inflammation, that is, highly elevated C-reactive protein (CRP) (161 mg/l), and erythrocyte sedimentation rate (ESR) (46 mm/h) values, accompanied with leukocytosis (12,100 cells/cu mm) and thrombocytoses (524,000 cells/ku mm). Urine culture showed Enterococcus spp. sensitive to linezolid and nitrofurantoin. A bone marrow aspiration and biopsy was done including culture for bacterial, mycobacterium and fungus. Treatment of arthritis in HIV-infected children can be challenging. It is crucial to recognize the arthritic manifestation of HIV infection in order to avoid delaying diagnosis and starting proper treatment.

Case report: Safety and efficacy of adalimumab in treating difficult-to-treat rheumatoid arthritis in a human immunodeficiency virus-positive patient, one year follow-up

Rheumatoid arthritis (RA) is a joint-disabling inflammatory disease associated with the pathology of synovitis. Some patients with RA are difficult to treat, using disease-modifying anti-rheumatic drugs (DMARDs). Biology and targeted synthetic DMARDs (b/tsDMARDs) are options for patients with RA. Acquired immunodeficiency syndrome (AIDS) is an infectious disease caused by the human immunodeficiency virus (HIV). Adalimumab is an anti-tumor necrosis factor therapy commonly used in patients with RA. However, there are no reports or related data on patients with RA-HIV/AIDS treated with adalimumab are available. In this report, we described the first successful case of a 60-year-old HIV-positive woman with difficult-to-treat RA treated with ADA after being screened for hepatitis virus, latent tuberculosis (LTBI), and other infections. She contracted HIV from sexual exposure while on adalimumab therapy. As the patient was resistant to first-line DMARDs, she continued adalimumab along with the initiation of highly active antiretroviral therapy (HAART). The patient was treated with adalimumab therapy for a year; her CD4+ lymphocyte count was normal, HIV-1 RNA decreased, and no new infections were triggered. The patient achieved clinical remission of RA. In conclusion, adalimumab is a safe option for patients with RA-HIV and may slow the progression of HIV infection. Furthermore, HAART has the potential to reduce joint pain and fatigue in patients with difficult-to-treat RA.

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.

A smart nanosensor for the detection of human immunodeficiency virus and associated cardiovascular and arthritis diseases using functionalized graphene-based transistors

Human immunodeficiency virus (HIV), which isa worldwide public health issue, is commonly associated with cardiovascular disorders (CVDs) and rheumatoid arthritis (RA). A smart nanosensor was developed for the detection of HIV and its related diseases (CVDs and RA) using graphene-based field-effect transistors (FETs). In this study, amine-functionalized graphene (afG) was conjugated with antibodies [anti-p24 for HIV, anti-cardiac troponin 1 (anti-cTn1) for CVDs, and anti-cyclic citrullinated peptide (anti-CCP) for RA] to detect various biomarkers. The antibodies were covalently conjugated to afG via carbodiimide activation. The bioconjugate (graphene-antibody) was characterized by various biophysical techniques such as UV-Vis, Raman spectroscopy, scanning electron microscopy (SEM), and atomic force microscopy (AFM). The electrochemical performance of the sensor was evaluated with respect to changes in the resistance of the electrode surface due to the interaction of the antigen with its specific antibody. The developed sensor was highly sensitive and showed a linear response to p24, cTn1, and, CCP from 1 fg/mL to 1 μg/mL. The limit of detection (LOD) was 100 fg/mL for p24 and 10 fg/mL for cTn1 and CCP under standard optimized conditions. The graphene-based smart nanodevice demonstrated excellent performance; thus, it could be used for the on-site detection of HIV, CVD, and RA biomarkers in real samples.

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.

Inflammatory arthritis in HIV positive patients: A practical guide

Background

Musculoskeletal manifestations of the human immunodeficiency virus (HIV) have been described since the outset of the global HIV epidemic. Articular syndromes that have been described in association with HIV include HIV-associated arthropathy, seronegative spondyloarthropathies (SPA) (reactive arthritis, psoriatic arthritis (PsA) and undifferentiated SPA), rheumatoid arthritis (RA) and painful articular syndrome.

Methods

We carried out a computer-assisted search of PubMed for the medical literature from January 1981 to January 2015 using the keywords HIV, acquired immune-deficiency syndrome, rheumatic manifestations, arthritis, spondyloarthropathy, anti-TNF and disease modifying antirheumatic drugs. Only English language literature was included and only studies involving adult human subjects were assessed.

Results

There are challenges in the management of inflammatory arthritis in patients who are HIV-positive, including difficulties in the assessment of disease activity and limited information on the safety of immunosuppressive drugs in these individuals.

Conclusions

This review focuses on the clinical characteristics of the inflammatory articular syndromes that have been described in association with HIV infection and discusses the therapeutic options for these patients.

Update on imaging of non-infectious musculoskeletal complications of HIV infection

Acquired immunodeficiency syndrome (AIDS) results from infection with human immunodeficiency virus (HIV), producing an immunodeficient state and severe pathology across multiple organ systems. Musculoskeletal involvement is particularly prevalent in this population with both infectious and non-infectious complications encountered, but it is suggested that the latter will affect 72% of HIV-infected individuals. In this review we aim to provide an update on the imaging characteristics of the non-infectious manifestations. The conditions include HIV-related arthritis as well as various malignancies, myositis, anaemia, osteonecrosis, rhabdomyolysis, hypertrophic osteoarthropathy and therapy-related side effects. For the clinician, the diagnostic challenge lies in differentiating disease-related symptoms from therapy-related side effects, particularly when clinical and laboratory features can be non-specific. This is especially difficult following the widespread introduction of highly active anti-retroviral therapy (HAART). Imaging investigations and MRI in particular have proven vital for facilitating early diagnosis and enabling prompt treatment. Furthermore, wider availability of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) has allowed whole-body assessment for staging and treatment response of malignancy. Understanding the pathogenesis of the various conditions and recognising their imaging features is essential for the clinical radiologist.

Rheumatic conditions in human immunodeficiency virus infection

Many rheumatic diseases have been observed in HIV-infected persons. We, therefore, conducted a comprehensive literature search in order to review the prevalence, presentation and pathogenesis of rheumatic manifestations in HIV-infected subjects. Articular conditions (arthralgia, arthritis and SpAs) are either caused by the HIV infection itself, triggered by adaptive changes in the immune system, or secondary to microbial infections. Muscular symptoms may result from rhabdomyolysis, myositis or from side-effects of highly active anti-retroviral therapy (HAART). Osseous complications include osteonecrosis, osteoporosis and osteomyelitis. Some conditions such as the diffuse infiltrative lymphocytosis syndrome and sarcoidosis affect multiple organ systems. SLE may be observed but may be difficult to differentiate from HIV infection. Some anti-retroviral agents can precipitate hyperuricaemia and are associated with arthralgia. When indicated, immunosuppressants and even anti-TNF-alpha agents can be used in the carefully monitored HIV patient. Thus, rheumatic diseases and asymptomatic immune phenomena remain prevalent in HIV-infected persons even after the widespread implementation of highly active anti-retroviral therapy.

Infection and musculoskeletal conditions: Rheumatologic complications of HIV infection

The pandemic caused by the human immunodeficiency virus (HIV) has entered its second quarter-century, with 40 million people now affected worldwide - particularly in Africa, where the impact has been most devastating. A complex array of rheumatic disease manifestations has been described, including diseases specific to HIV infection such as HIV-associated arthritis and the diffuse infiltrative lymphocytosis syndrome; other conditions which occur prominently in HIV-positive individuals include vasculitis, reactive and psoriatic arthritis and HIV-associated polymyositis, opportunistic musculoskeletal infections, and finally disorders that were originally ameliorated by HIV infection, such as rheumatoid arthritis and lupus. Effective antiretroviral treatment ameliorates many of these disorders; however, the introduction of highly active antiretroviral treatment (HAART) has introduced a new spectrum of disorders and new challenges confronting the clinician, including osteonecrosis, rhabdomyolysis, and, with immune reconstitution, the appearance de novo of a variety of autoimmune disorders and phenomena.

Rheumatic manifestations of human immunodeficiency virus infection

Rheumatic complaints are common in patients with HIV, and HIV positivity confers an increased susceptibility in populations with similar risk factors for HIV infection. With the advent of the modern combined antiretroviral treatment, HAART has had a profound beneficial effect on survival in HIV-infected patients, with lifelong control of HIV infection and normalization of life expectancy; but it has also contributed to both an altered frequency and a different nature of rheumatic complications now being observed in this population, with new rheumatic complications, such as osteoporosis, osteonecrosis, gout, mycobacterial, mycotic osteoarticular infections, and neoplasia perhaps more prevalent. Rheumatologists, internists, and general physicians need to be aware of these changes to provide optimal diagnosis and how to disclose the results to their patients. They also need to be familiar with the management of HIV infection and to direct careful attention to the prevention of HIV transmission in health care facilities.

Early Oligoarthritis

Oligoarthritis is a common condition, with a variable outcome, affecting a predominantly young population; when treated conventionally, oligoarthritis has a high morbidity. The variability of outcome has limited the development of studies evaluating therapies such as disease-modifying antirheumatic drugs in recent onset disease. Oligoarthritis is an important disease that warrants much greater study.

Seronegative spondyloarthropathies: to lump or split?

The advent of novel biological therapies for the treatment of rheumatic disease has renewed interest in the seronegative spondyloarthropathies (SpAs). International efforts are redefining disease classification and measures of disease activity, outcome, metrology, and imaging. However, opinion is divided between those who propose that the SpA group represents the same disease with variable expression (the "lumpers") and those who consider these to be separate diseases with shared clinical features (the "splitters"). This review presents the evidence for both approaches.

Is inflammatory joint disease in HIV-infected patients a form of spondyloarthropathy?

In Congo-Brazzaville, the seroprevalence of HIV infection is in the range 7-8%, and AIDS is the leading cause of aseptic arthritis (60% of cases).

PATIENTS, MATERIAL AND METHODS

The ESSG and Amor's criteria for spondyloarthropathy were evaluated in 83 patients with HIV infection admitted for aseptic arthritis to the rheumatology department of the Brazzaville teaching hospital, over an 8-year period.

RESULTS

All 83 patients were CDC stage IV; 66 (80%) had polyarthritis and 17 (20%) oligoarthritis. A single patient met ESSG and Amor's criteria, with six points; one patient had five points and 15 had three points. The joint involvement was asymmetrical and nonerosive. Nonsteroidal antiinflammatory therapy ensured resolution of the manifestations within 4-8 weeks. The most common sites of involvement were the knees (84%), ankles (59%), and great toes (23%) at the lower limbs and the wrists (41%), elbows (29%), and metacarpophalangeal and interphalangeal joints (25%) at the upper limbs.

CONCLUSION

Inflammatory arthritis in HIV patients does not meet ESSG or Amor's criteria for spondyloarthropathy.

Rheumatic manifestations of human immunodeficiency virus

Since July 1983, various rheumatic, musculoskeletal, or other immune disorders characterized by dysregulation have been associated with HIV and AIDS. Infections occur, but with a lower frequency than expected in a patient population with a disorder primarily characterized by significant cellular immune deficiencies. Reactive arthritis, psoriatic arthritis, acute nonspecific arthritis, Sjögren syndrome, and inflammatory myositis have been reported. The initial reports of "acute painful joints," however, have not maintained prominence in the literature. A review of the literature over the past several years has reinforced the perception that the initial excitement over a possible association between HIV and AIDS and rheumatic or definable autoimmune disorders remains limited to a small segment of illnesses dominated by the reactive arthritidies.

Rheumatic manifestations of human immunodeficiency virus infection

Rheumatic complaints are common in patients with human immunodeficiency virus (HIV) infection. With the advent of the modern combined antiretroviral treatment, life-long control of HIV infection and normalization of life expectancy in HIV-positive patients have become realistic perspectives, but new rheumatic complications, such as osteoporosis, osteonecrosis, gout, and mycobacterial and mycotic osteoarticular infections may be more prevalent. Rheumatologists, internists, and general physicians need to be familiar with the presentation and treatment of these conditions in HIV-positive patients.

Immune linkages between inflammatory bowel disease and spondyloarthropathies

Gut involvement is a prominent feature of spondyloarthropathy (SpA). Analysis of immune alterations of the gut in SpA have shown two distinct aspects. On the one hand, gut inflammation in SpA seems closely related with gut inflammation seen in Crohn disease. On the other hand, gut inflammation in SpA is associated with peripheral joint inflammation. Recent studies have provided new insights into this gut-synovium axis. First, there is little new evidence to support the concept of viable microbial pathogens recirculating to the joint. In contrast, it seems likely that both bacterial antigens and reactive T cell clones home to the joint, and that adhesion molecules such as the beta7 integrins and VAP1 play an important role in this process. Second, there is increasing evidence that the different disease localizations in SpA are characterized by alterations of the innate immune system, which contribute to a breakdown of the immune tolerance and the creation of an inflammation-prone environment. Mediators of the innate immune system, such as scavenger receptors, interleukin-10 (IL-10), and tumor necrosis factor alpha (TNF-alpha), may therefore be interesting targets for therapeutic intervention, as illustrated by the effect of TNF-alpha blockade in SpA.