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HUMAN IMMUNODEFICIENCY VIRUS

Essentials of Diagnosis

  • The diagnosis of human immunodeficiency virus (HIV) is confirmed using a combination of a combined antigen/antibody immunoassay and an HIV viral load test.

  • A positive virologic test indicates HIV infection. Early disease is suggested by a negative immunoassay in the presence of viremia.

  • HIV infection is associated with a wide range of rheumatic syndromes. These can occur at any stage of the disease.

  • Rheumatic conditions that have been described in association with HIV include HIV-associated arthropathy, seronegative spondyloarthropathies, connective tissue diseases, vasculitides, septic arthritis, and pyomyositis.

General Considerations

Musculoskeletal manifestations of the human immunodeficiency virus (HIV) have been described since the outset of the global HIV epidemic. The first reports of rheumatologic symptoms of the infection occurred 3 years after its discovery, when Winchester et al described a case of reactive arthritis (ReA) in a patient with advanced acquired immunodeficiency syndrome (AIDS). HIV-positive patients with musculoskeletal involvement have reduced quality of life compared to those without rheumatic symptoms (Kole et al, 2013).

The HIV epidemic has also changed the epidemiology of certain diseases. As an example, HIV is associated with an increased incidence of spondyloarthropathies and psoriatic arthritis as well a greater severity of these conditions in patients with HIV. In addition, HIV and its treatment have led to the description of new conditions, namely HIV-associated arthropathy and antiretroviral-related myopathy. Finally, HIV has posed challenges to the management of common rheumatologic conditions, for example in the treatment of rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE).

Pathogenesis

A combination of immunodeficiency, immune hyperactivity, and dysregulated production or activity of cytokines such as tumour necrosis factor-α (TNF-α), interleukin (IL)-6, IL-12, interferon (IFN) gamma, and molecular mimicry may contribute to the rheumatic manifestations of HIV infection (Nguyen and Reveille, 2009). Potent antiretroviral therapy (ART) changes the course of HIV infection and may ameliorate some manifestations, it but may also contribute to the appearance of others (Lawson and Walker-Bone, 2012).

A. Symptoms and Signs

HIV-associated arthritis can occur at any stage of HIV illness. It can present in several ways: as an asymmetrical oligoarthritis, an symmetrical polyarthritis, or a monoarthritis (Plate and Boyle, 2003). The asymmetrical oligoarthritis variant, the most common form, has a male preponderance and predominately affects the knees and ankles. The symmetrical polyarthritis variant closely mimics RA, with patients exhibiting deformities similar to those of RA patients, including ulnar deviation. The polyarthritis of HIV is characterised by substantial acuity at onset but is usually nonerosive. The presence of Jaccoud arthropathy as part of an HIV-associated arthritis has also been described occasionally (Weeratunge et al, 2004). HIV-associated arthritis tends to be short lived, with a peak intensity occurring at 1–6 weeks. Some patients develop a chronic destructive arthropathy, however, associated with marked functional disability. Features of mucocutaneous involvement or enthesopathy ...

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