All immunodefficiency syndromes are related to rheumatological disorders. HIV also associated with joint manifestations:
Polymyositis can occur in the initial flu like symptoms of the initial exposure. Infections of the musculoskeletal system are common. A reactive arthritis may be the first manifestation of the disease. Rosenberg et al (1989) reported that in 20 patients with HIV and inflammatory arthritis, 54% had Reiter’s Syndrome, 17% psoriatic arthritis and 13% undifferentiated form of spondyloarthropathy. The arthritis is often severe and may progress rapidly. Azathioprine and methotrexate are contraindicated in those with HIV. SLE and rheumatoid arthritis have a low association with HIV/AIDS as they are mediated via the interaction of the MHC products and the CD4 lymphocytes – AIDS patients have very low CD4 counts.
Musculoskeletal complication in established HIV disease:
1) Myopathy:
• variable presentation – usually muscle aches that waxes and wanes – usually proximal, but often distal – eventually muscles atrophy
• in up to 35% of those with HIV
• Histologically similar to the autoimmune polymyositis
• inciting factors include change in drug regimen, infection or fever
• AZT myopathy can occur about 6 months after start of treatment
• treatment is removal of inciting agent and symptomatic management
2) HIV painful articular syndromes:
• self limiting
• acute type – rapid onset of pain in ankles or knees – extremely painful, usually cannot weight bear – usually symmetric – usually abates after 24 hours
• subacute type – gradual onset of joint pain over a period of weeks – usually knee (classic patellofemoral pain syndrome) or ankle – no effusions and whole area of joint is tender to palpation – most resolve over period of months.
• little known about pathology
• treatment – symptomatic: acute (narcotics); subacute (NSAID’s)
3) HIV associated arthritis:
• resemble subacute form of painful articular syndrome – but joint effusions are present
• develops over a period of up to a month – predilection for lower limb
• joint fluid is non-inflammatory; do not have HLA-B27 and do not have extrarticular features of Reiter syndrome
4) Reactive arthropathy:
• appears that there is an increased prevalence of Reiter syndrome’s, psoriatic arthritis and enthesopathy (undifferentiated seronegative spondyloarthropathy) in the HIV positive population; high prevalence of HLA-B27
• may precede onset of other HIV diseases by several years
• clinical presentation varies from local synovitis and enthesopathy to axial skeleton involvement.
• Achilles tendonitis and plantar fasciitis are common
5) Other:
• Those who are HIV positive also have higher frequencies of Sicca syndrome, lupus like syndromes, vasculitis and other autoimmune phenomena.
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