Inflammatory joint disease and human immunodeficiency virus infection

Spondyloarthropathies and arthritis post-infection: a historical perspective

The spondyloarthropathies are a group of conditions characterised by spinal joint pain and have related clinical, epidemiological and genetic-related features. Ankylosing spondylitis, reactive arthritis, the spinal form of psoriatic arthritis and Crohn's and colitis enteropathic arthritis are the major clinical entities of the spondyloarthropathies, and principally occur in HLA-B27 positive individuals. Ankylosing spondylitis is much more common in males than females. Patients are usually seronegative for rheumatoid factor, and extra-articular features including iridocyclitis, mucous membrane and skin lesions: aortitis, may occur in some patients. The reactive arthritis form classically occurs following an infection of the gastrointestinal or genitourinary tract. The Crohn's and colitis enteropathic arthritis forms often have an associated large joint asymmetrical arthritis. Also discussed are acute rheumatic fever and Lyme disease which are conditions where the individual develops arthritis after an infection.

Reactive arthritis: the convoluted history of Reiter's disease

Reactive arthritis, previously known as Reiter's Syndrome or Disease was a post-dysenteric, asymmetrical acute large joint polyarthritis, with fever, conjunctivitis, iritis, purulent urethral discharge, rash and penile soft tissue swelling. Although the eponym was given to Hans Reiter, various forms of the condition have been recorded in history a few hundred years before Reiter. Two French doctors, Noel Fiessinger (1881-1946) and Edgar Leroy (d. 1965), presented a paper at la Societe des Hopitaux-in Paris on the 8th December 1916 on dysentery in 80 soldiers on the Somme, and four of whom developed a "syndrome conjunctivo-uretro-synovial". Their paper was given 4 days before Reiter's presentation on 12th December 1916 at the Society of Medicine in Berlin, on a German army officer with an illness similar to those described by Fiessinger and Edgar Leroy. It is documented that Hans Reiter was one of a number of University professors who signed an oath of allegiance to Adolf Hitler in 1932. For socio-ethical reasons and for clinical utility, Reiter's syndrome is now known as reactive arthritis.

Musculoskeletal and rheumatological disorders in HIV infection: Experience in a tertiary referral center

Background:

Musculoskeletal involvement in human immunodeficiency virus (HIV) infected patients are important disease manifestations, responsible for increased morbidity and also decreased quality of life.

Objectives:

To study the spectrum of different musculoskeletal involvement in HIV infected patients and its impact on quality of life.

Patients and Methods:

Three hundred (n = 300) HIV-1 reactive patients were evaluated in respect to different musculoskeletal involvement including the quality of life from January 2010 to January 2011.

Results:

Male to female ratio was 11:1 with a mean age of 35 (±6.4) years and mean duration of the disease was 3 (±1.54) years. Majority of cases were truck drivers, motel workers, and jewelry workers. Musculoskeletal disorders were observed in a total of 190 cases (63.33%). The spectrum of musculoskeletal involvement was: Body ache in 140 (46.7%), arthralgia in 80 (26.7%), mechanical low back pain in 25 (8.3%), osteoporosis in 20 (6.7%), painful articular syndrome in 10 (3.3%), hypertrophic osteoarthropathy in two (0.7%), pyomyositis in two (0.7%), osteomyelitis in one (0.3%), and avascular bone necrosis in one patient (0.3%). Rheumatologic disorders associated were: Reactive arthritis in seven (2.3%), fibromyalgia in four (1.3%), septic arthritis in three (1%), acute gout in three (1%), spondyloarthropathy in two (0.7%), rheumatoid arthritis in two (0.7%), dermatomyositis in one (0.3%), and systemic lupus erythematosus (SLE) in one patient (0.3%). But HIV associated arthritis and diffuse infiltrative lymphocytosis syndrome (DILS) were not detected. Most of the patients had decreased quality of life.

Conclusions:

Musculoskeletal involvement was common in HIV patients causing increased morbidity, so early detection and timely intervention is essential to improve quality of life.

Uveitis in children with human immunodeficiency virus-associated arthritis

PURPOSE

To describe the ocular inflammatory manifestations and clinical characteristics of children with Human Immunodeficiency Virus (HIV)-associated arthritis.

METHODS

A retrospective review of the charts of children with chronic uveitis and HIV-associated arthritis seen between June 2004 and September 2006 at Inkosi Albert Luthuli Central Hospital, Durban, South Africa. The following data were analyzed: age at presentation, gender, race/ethnicity, rheumatologic problems, uveitic diagnosis, laboratory findings, and ocular complications.

RESULTS

Seven black African males with a mean age of 9 years (range, 4 to 13 years) were identified. There were no other significant laboratory findings apart from HIV; all patients were antinuclear antibody negative. Arthritis was polyarticular in 6 patients and pauciarticular in 1. Four patients had intermediate uveitis and 3 patients had nongranulomatous anterior uveitis. Visual acuity ranged from 20/20 to hand movements. Ocular complications included cataract, cystoid macular edema, hypotony, pupillary membranes, band keratopathy, posterior synechiae and optic disk edema.

CONCLUSIONS

HIV-associated arthritis and uveitis in children is a clinical syndrome that may be associated with severe sight-threatening intraocular inflammation. Routine eye screening in HIV-positive children, particularly those with arthritis, is warranted to facilitate prompt treatment.

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.

Etiology of reactive arthritis inPan paniscus, P. troglodytes troglodytes, andP. troglodytes schweinfurthii

The character of arthritis has not received the same attention in Pan paniscus as it has in P. troglodytes. Reactive arthritis (a form of spondyloarthropathy) in the latter has been considered to be either a sexually transmitted or an infectious-agent diarrhea-related disorder. The unique sexual promiscuity of P. paniscus enables us to distinguish between those hypotheses. The macerated skeletons of 139 adult P. paniscus, P. troglodytes troglodytes, and P. troglodytes schweinfurthii were macroscopically analyzed for osseous and articular pathologies. The sex of the animal was recorded at the time of acquisition. Twenty-one percent of the P. paniscus, 28% of the P. t. troglodytes, and 27% of the P. t. schweinfurthii specimens had peripheral and central joint erosive disease characteristic of spondyloarthropathy. Subchondral pauciarticular distribution and reactive new bone clearly distinguish this disease from rheumatoid arthritis, osteoarthritis, and direct bone/joint infection. The fact that P. paniscus and P. t. troglodytes were similar in terms of disease frequency makes the notion of sexual transmission unlikely. While the frequencies of spondyloarthropathy were indistinguishable among all species/subspecies studied, the patterns of joint involvement were disparate. The Pan paniscus and P. t. troglodytes home ranges are geographically separate. We assessed possible habitat factors (e.g., exposure to specific infectious agents of diarrhea) by comparing P. paniscus and P. t. troglodytes with P. t. schweinfurthii. The latter shared similar patterns and habitats (separated by the Congo River) with P. paniscus. The explanation offered for habitat-specific patterns is differential bacterial exposure-most likely Shigella or Yersinia in P. paniscus and P. t. schweinfurthii.

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.

Rheumatic manifestations of HIV-AIDS

Infection by human immunodeficiency virus is characterized by a myriad of clinical manifestations affecting almost every organ system in the body. If untreated, it follows an inexorable course, leading to a profound state of immunosuppression and eventually death from opportunistic infection and/or development of lymphoproliferative malignancy and Kaposi's sarcoma. Rheumatic manifestations may develop at any time of the clinical spectrum, but usually are more often seen in late stages. A variety of disorders may be seen, particularly Reiter's syndrome and undifferentiated spondyloarthropathy. Most patients do well with conventional anti-inflammatory therapy, but some will require the use of immunosuppressive-cytotoxic therapy.

Features of spondyloarthritis around the world

This article elucidates the prevalence and pathogenic roles of the MHC and microbial infections and clinical features and treatment of SpA across different populations from the arctic and subarctic regions to Central America, Asia, and Africa. Preliminary evidence suggests significant genetic and environmental influences on the onset and presentation of SpA, particularly AS, in these populations, which are different than those reported in white Caucasians; however, community surveys and longitudinal and case control studies are difficult to undertake in many of the developing countries. Thus, most of the currently available data have been devised from short-term and retrospective studies and should be treated with caution. Differences in referral and follow-up practices and the availability of rheumatology expertise and relevant resources may explain some of the differences observed in the populations discussed in this article. Furthermore, widely accepted criteria for the classification of SpA may not be applicable to non-Caucasians and need to be evaluated in these subjects. With gradual improvement in the economic status in many of the developing countries in Asia and Africa, it is hoped that with improvement in medical services, more physicians and specialty clinics in rheumatology, and changing referral patterns, better documentation of the various aspects of different SpA can be achieved. Future research should focus on the evaluation of specific risk or protective factors in population groups to better delineate the relative importance of genetic and environmental effects in the pathogenesis of SpA.

Reactive arthritis

Reactive arthritis (ReA) develops after an infection elsewhere in the body, generally in the genitourinary or intestinal tract. Chlamydia trachomatis, Yersinia enterocolitica, salmonella, shigella, and campylobacter are frequent triggering agents. Between 60% and 90% of patients are positive for HLA-B27. The arthritis occurs within 4 weeks of the primary infection and is oligoarticular and asymmetric. Extra-articular manifestations include mucocutaneous symptoms, ocular inflammation, and urethritis. The average duration of arthritis is 4 to 5 months but two-thirds of patients have symptoms for more than a year. Bacterial antigens have been found in synovial specimens from patients with ReA, but cultures are sterile. The treatment of ReA comprises non-steroidal anti-inflammatory drugs, intra-articular steroid injections, and physical treatment. Short-term antibiotic treatment has no effect in manifest ReA, whereas a tendency to improvement has been seen with treatment over months, at least after chlamydia infection.

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.

Rheumatic manifestations in 556 patients with human immunodeficiency virus infection

We studied in retrospect the rheumatic manifestations of 556 patients with human immunodeficiency virus (HIV) infection. Eighty percent were men. Eighty-six percent were intravenous drug abusers (IVDAs), 9% homosexual, 3% partners of high-risk persons having the infection, 0.4% hemophiliacs, and 2% had no known risk factors. We found rheumatic disorders in 63 (11%) patients. The most frequent findings were myalgias and/or arthralgias (4.5%; one patient had an inflammatory myopathy), skeletal infections (3.6%), and arthralgias (1.6%). Reiter's syndrome and seronegative arthritis were present only in 0.5%, and HIV-associated arthritis and vasculitis in 0.4%, respectively. Skeletal infections were caused predominantly by Staphylococcus aureus (60%) and Candida albicans (20%). All these patients were IV drug abusers whose clinical features were similar to those previously described in skeletal infections of non-HIV-infected IVDAs. Comparing these data with other studies composed primarily of homosexual men where Reiter's syndrome is the predominant rheumatic disorder, we conclude that the type of rheumatic complaint is more related to the risk factors than to HIV itself.

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.

AIDS virus infection and autoimmunity: a perspective of the clinical, immunological, and molecular origins of the autoallergic pathologies associated with HIV disease

The acquired immune deficiency syndrome (AIDS) is a viral-induced disorder of humans that is reaching pandemic proportions. The etiologic agent responsible for AIDS is recognized as a retrovirus termed the human immunodeficiency virus (HIV). This virus is both cytotropic and cytopathic for T lymphocytes in vitro, and patients with AIDS and HIV-related conditions invariably have serious T cell abnormalities, notably a reduced number of the helper/inducer (CD4+) subpopulation. There is now a substantial body of evidence to suggest that the AIDS virus triggers a diverse range of autoimmune phenomena. The purpose of this article is to summarize the clinical and immunopathological manifestations of autoimmunity in HIV infection and to provide a perspective of the possible origins and roles autoimmune reactions play in HIV disease progression.

The role of tumour necrosis factor-alpha in acquired immunodeficiency syndrome

Tumour necrosis factor-alpha (TNF) is a primary mediator in the pathogenesis of infection, tissue injury and inflammation. It is synthesised by various activated, phagocytic and non-phagocytic cells, and a wide variety of infectious or inflammatory stimulae are capable of triggering TNF biosynthesis. Recent studies indicate that overproduction of TNF in septicaemia is a critical step in triggering septic shock and multiple organ damage. Intravenous administration of recombinant human TNF induced the same types of derangement in cardiovascular homatologic, inflammatory and metabolic homeostasis that are found with endotoxic or septic shock. Chronic TNF production causes a potentially lethal syndrome of cachexia, anaemia, and protein and lipid wasting. Several investigators have recently demonstrated elevated levels of serum TNF in patients with acquired immunodeficiency syndrome (AIDS), these levels being closely correlated with the severity of the disease. This review discusses the role of TNF in the pathophysiology of AIDS and of several disorders associated with the latter. In addition, it discusses the interactions between TNF and several agents used in AIDS therapy, and suggests the use of TNF-antagonists in combination as a therapeutic regimen for AIDS patients.

Sexually transmitted arthritis syndromes

Sexually transmitted infections may provoke a wide variety of rheumatic lesions. Disseminated N. gonorrhoeae infection leads to septic arthritis, which may be rapidly destructive but which responds promptly to appropriate antibiotic therapy. In contrast, both gonococcal and nongonococcal infections may lead to aseptic "reactive" arthritis or Reiter's syndrome. Inheritance of HLA B27 confers a relative risk of 30 to 50 times for the development of this condition. The demonstration of C. trachomatis antigen in joint material from a minority of patients suggests that direct interaction between microbial components and class I HLA antigens in the joint may be central to the pathogenesis of this disease. Arthralgia and arthritis occur in up to 50% of individuals in the prodrome of hepatitis B infection. Joint symptoms may be accompanied by urticarial or cutaneous vasculitic lesions, especially on the legs; both features resolve with the onset of jaundice. Hepatitis B infection is also a major cause of necrotizing vasculitis, which may or may not be associated with overt hepatitis. Seronegative arthritis, including Reiter's syndrome, psoriatic arthritis, and undifferentiated arthritis, a Sjögren's-like syndrome, vasculitis, and myopathies have been described in association with HIV infection. It is clear that synovitis occurs in those patients despite the fact that HIV is present in immune cells within the joint during inflammatory arthritis and that both antigen presentation and lymphocyte responsiveness within the joint are impaired. Nevertheless, synovitis may occur in the presence of marked CD4-positive lymphocyte depletion. Rheumatic syndromes, including arthralgia, inflammatory arthritis, and neuropathic arthritis, may occur during any stage of congenital or acquired syphilis. Syphilitic synovitis responds well to antibiotic therapy, but neuropathic lesions cannot be treated effectively. Septic arthritis has rarely been described as a complication of disseminated Mycoplasma or Urea-plasma infections, and joint lesions sometimes associated with erythema nodosum have also been reported in lymphogranuloma venereum and granuloma inguinale.

Human immunodeficiency virus-associated psoriasis, psoriatic arthritis, and Reiter's syndrome: a disease continuum?

The presence of peripheral arthritis and HLA-A, B, C, DR, and DQ antigens was evaluated prospectively in 18 Caucasian men with human immunodeficiency virus-associated psoriasis. An asymmetric polyarthritis occurred in 32% of the patients and correlated with the presence of HLA-B27. Extensive clinical overlap between psoriatic arthritis, psoriasis, and Reiter's syndrome was noted. No significant excess of the HLA antigens previously found to be associated with psoriasis was seen, which suggests that human immunodeficiency virus-associated psoriasis per se may instead constitute another form of spondylarthropathy that is more closely related to Reiter's syndrome.

Infection of nonlymphoid cells by human immunodeficiency virus type 1 or type 2

Human epithelial cells (L132) derived from embryonic lung and human lung fibroblasts (MRC5) were infected by human immunodeficiency virus type 1 (HIV-1) or type 2 (HIV-2). Surface CD4 protein was detected on these cells, and recombinant soluble CD4 (sCD4) blocked infection, indicating that HIV infection was mediated by the cell surface CD4 protein. In contrast, infection of human primary chondrocyte cells (C23), synovial cells (HSA), and foreskin fibroblasts (F13) was apparently independent of cell CD4-mediated mechanisms. Surface CD4 protein could not be detected on these cells, and sCD4 did not block the infection. F13 cells could be infected only by HIV-2, not by HIV-1, under our experimental conditions. In cells of mesenchymal orgin, viral production could be detected only after cocultivation with the human T-lymphoid H9 cells but not by conventional viral assays, including reverse transcriptase and p24 antigen assays in cell culture supernatant and immunofluorescence of host cells. Our DNA transfection studies indicated that this lack of detectable viral production was not due to the inefficient use of the HIV long terminal repeat or the Tat protein in these cells. These mesenchymal and epithelial cells were susceptible to HIV infection but differed in mechanism of virus entry compared with hematopoietic cells such as T lymphocytes. These observations may provide insights into clinical syndromes such as lung dysfunction in HIV-infected newborns and connective tissue disorders in HIV-infected adults.

Chronic acquired immunodeficiency syndrome-associated arthritis: a synovial ultrastructural study

We describe a patient who developed acquired immunodeficiency syndrome-related complex, complicated by chronic, symmetric polyarthritis. Synovial biopsy showed large areas of plasma cell infiltration subjacent to the synovial lining. Ultrastructural study demonstrated tubuloreticular structures within endothelial cells, crystal-like inclusions in plasma cells, and virus-like particles located around synoviocyte fragments. Although immunologic and morphologic studies did not permit classification of these virus-like structures, the role of these possible virions in the pathogenesis of the observed synovitis remains to be determined. Surprisingly, the patient's chronic arthritis resolved with anti-retroviral treatment (azidothymidine: AZT).

Seronegative arthritis and the bowel

In this chapter we have outlined the seronegative spondarthritides associated with bowel disease, excluding those discussed in separate chapters. Although, traditionally, Crohn's disease and ulcerative colitis have been dealt with separately in any discussion of seronegative arthritides, they have been discussed together here for the following reasons. Despite being pathologically distinct they show remarkable similarity in extraintestinal manifestations including any associated arthritis. Any observed differences in prevalence rates of arthritis may be secondary to the relative difficulty in diagnosing Crohn's disease, and most of the important prevalence studies were done before the more sophisticated techniques to investigate the bowel became available. This may in part explain the dramatic increase in the world-wide incidence of Crohn's disease seen in the last 30 years, particularly through the 1970s, but which has fallen off recently (Miller et al, 1974). It would seem that the body has a limited means of expressing disease processes. The final common pathway of a number of quite distinct disease entities is the concept of the seronegative spondarthritides. Exactly how the microbiological, immunogenetic and molecular factors interact to produce a particular disease end-point is currently not clearly defined, but with the increasingly sophisticated means to investigate the body at a cellular level the explanations may soon be at hand. Further controlled family studies are also needed to define the genetic relationships more precisely. We may then be able to piece the jigsaw puzzle together.