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The human retrovirus HIV infects an estimated 33 million people worldwide. Other retroviruses (eg, human T-lymphotropic virus type I) have been reported to be associated with inflammatory arthropathies, so it is not surprising that a number of rheumatologic manifestations have been described in HIV-infected persons (Table 51–1). These include various arthropathies, muscle diseases, bone disorders, symptoms and signs mimicking Sjögren syndrome, and systemic vasculitis. For some of these disorders, a clear pathophysiologic association with HIV has been established. For others, true relationships remain speculative. Geographic predisposition among HIV-infected persons to certain rheumatologic conditions is suggested by a number of studies.

Table 51–1. Musculoskeletal Manifestations of HIV Infection.

Essentials of Diagnosis

  • Diagnosis of HIV infection is made by serologic tests (enzyme-linked immunosorbent assay) and confirmed by Western blot.
  • HIV causes nonspecific B-cell activation resulting in a polyclonal hypergammaglobulinemia and a high frequency of false-positive autoantibody tests.
  • Rheumatologic manifestations include arthralgias, increased severity (and possibly increased incidence) of seronegative spondyloarthropathies, musculoskeletal infections, osteopenia/osteoporosis, and avascular bone necrosis.
  • Myalgias with minimal laboratory evidence of muscle damage are consistent with several conditions, including fibromyalgia, the HIV wasting syndrome, and antiretroviral toxicity.
  • Limited data suggest that highly active antiretroviral therapy (HAART) may be associated with several rheumatologic complications including arthralgias, myopathies, and abnormalities in bone mineralization.
  • Concomitant use of HAART and immunosuppressive agents requires careful consideration of drug interactions, heightened toxicities, and difficulty in monitoring certain clinical HIV-related parameters.

General Considerations

Patients with HIV have heightened activation of the B-cell compartment and a high prevalence of polyclonal hypergammaglobulinemia. Partly as a consequence of this, the frequency with which autoantibody production is detected in patients with HIV is increased compared with healthy persons. The interpretation of positive autoantibody assays (eg, antinuclear antibodies, rheumatoid factor, and antineutrophil cytoplasmic antibodies) may be complicated in patients with HIV. Correlation between the laboratory and clinical findings is important.


HIV infection may modulate the host immune response contributing to the development of various rheumatic manifestations. Painful articular syndrome and HIV-associated arthritis represent distinct clinical syndromes that develop during the course of HIV infection, suggesting a direct role for HIV. The role of HIV in reactive arthritides, undifferentiated spondyloarthropathies, and musculoskeletal infections is most likely indirect, either by increasing susceptibility or influencing the clinical course of these diseases in susceptible patient groups. A unique spectrum of rheumatic manifestations has been recently recognized among HIV-infected persons treated with highly active antiretroviral therapy ...

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