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The Musculoskeletal system HIV and other infections
Johan van Rensburg
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HIV AND THE MUSCULOSKELETAL SYSTEM
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Important concepts in HIV and the musculoskeletal system
Concerning the HIV infection HIV modifies the presentation, clinical picture and outcome of auto-immune
diseases HIV infection may mimic many auto-immune diseases Auto-antibodies may be present in both HIV (low titers) and auto-immune
diseases Considering immune suppression
HIV-virus more responsible for manifestations in early disease Opportunistic infections and malignancies more prominent in late disease
Concerning the drugs The drugs used to modify auto-immune disease may modify the outcome of
HIV infection HAART may present with musculoskeletal adverse events Drug interactions must always be considered
Associated conditions Same principles of diagnosis and management apply as in patient without HIV
(after consideration of the above)
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Musculoskeletal manifestations in HIV
More prevalent in late stagesWide spectrum of diseasePrevalence uncertain
Quality of life influenced by pain, loss of function and systemic complications
Risk factors for HIVSexual historyIDUHemophiliacs
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Examples of HIV and MS System
Keep the normal course of HIV infection in mind
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Remember Components of the MS-system
Soft tissue Muscles
• Miopathy (virus and drugs), miositis (inflammatory or infective) Ligaments and enthesis
• involved in reactive athritis and other sero-negative spondyloarthropathies Blood vessels
• Vasculitis, drug reactions and coagulopathies Fat and other connective tissue
• Involved in infection, drug reactions and crystal induced inflammation Joints
Synovial joints • Infective: virus, septic arthritis, TB• Reactive • Auto-immune
Fibrous joints• Reactive athritis and other sero-negative spondyloarthropathies
Bone Infections Malignancies
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Muscles
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POLYMYOSITIS (HIV MYOPATHY)
Any stage of HIVPresents with
Bilateral proximal muscle weakness
Elevated CK levelsPathogenesis uncertainDiagnosis
Electromyography MRI Muscle biopsy (Nerve conduction
studies)Treatment limited
HAART Corticosteroids
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PYOMYOSITiS Advanced HIV Presents with
Insidious muscle pain & swelling
With or without systemic symptoms
Requires prior muscle injury Imaging
CTMRISonar
TreatmentAnti-microbialsSupportiveSurgery
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NRTI MYOPATHY
Long term useDose-related mitochondrial toxicity
Prevalence 17%Clinical picture
Similar presentation to polymyositisKeep lactic acidosis in mind
ManagementDiscontinuation
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Joints
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Related to HIV virus
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ARTHRALGIA
Early disease Acute HIV syndrome
Most patients seek medical attentionFever, fatigue, maculopapular rash50-70% myalgias, arthralgias, paresthesias
Painful Articular Syndrome10% of HIV patients
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ACUTE SYMMETRIC POLYARTHRITIS
Resembles rheumatoid arthritis Characterized
Swan neck deformities Ulnar deviation of the hand & digits Radiographic results
Non erosive Differentiation from RA
Atypical onset RF usually negative (may be low positive
with HIV) Anti-CCP negative in HIV
Treatment HAART Symptomatic Corticosteroids Chloroquin
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HIV ASSOCIATED ARTHROPATHY
Acute asymmetric oligoarthritis (Occurs late)Resembles reactive arthritisPresents
Acute severe painLarge joints6 weeks to 6 monthsNegative HLA B27 and RF
TreatmentHAARTSymptomaticCorticosteroids
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Opportunistic infections and other auto-immune diseases
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REITERS SYNDROME (Reactive arthritis)
Prevalence controversial 5-10%Pathogenesis
HLA B27 positivity (more susceptible)
Clinical picture “Incomplete” Reiter’s syndrome Assymetrical arthritis and enthesopathies Extra-articular manifestations
TreatmentHAARTSymptomaticCorticosteroidsSalazopyrin
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PSORIATIC ARTHROPATHY
Prevalence 3%10-40 X more frequent
in HIV infected patientsClinical picture
resembles psoriasis in the general population but may be more severe
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HYPERTROPHIC OSTEOARTHROPATHY
Associated with PCP Bronchus Ca
Clinical picture Severe pain in lower extremity Clubbing Arthralgias/periarticular soft tissue inflammation Non-pitting oedema
Special investigations Radiography
Periosteal reaction Scintigraphy Inflammation of distal ends of long bones
Treatment Underlying cause
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AVASCULAR NECROSIS AVN and HAART
Possible link HIV related risk factors
Corticosteroid Megestrol Hyperlipidemia Pancreatitis
Non HIV related risk factors Alcoholism Hypercoagulability Smoking
Common sites Femoral head Humeral head Lunate (Kienbock disease) Scaphoid (Preiser disease)
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Musculoskeletal infections in HIV
Septic ArthritisTuberculosis
OsteomyelitisBacillary
AngiomatosisToxoplasmosis
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Other conditions affecting the musculoskeletal system in HIV
Non-Hodgkin Lymphoma
Rhabdomyolysis
Myesthenia Gravis
Nemaline (Rod) myopathy
Fibromyalgia
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Important concepts in HIV and the musculoskeletal system
Concerning the HIV infection HIV modifies the presentation, clinical picture and outcome of auto-immune
diseases HIV infection may mimic many auto-immune diseases Auto-antibodies may be present in both HIV (low titers) and auto-immune
diseases Considering immune suppression
HIV-virus more responsible for manifestations in early disease Opportunistic infections and malignancies more prominent in late disease
Concerning the drugs The drugs used to modify auto-immune disease may modify the outcome of
HIV infection HAART may present with musculoskeletal adverse events Drug interactions must always be considered
Associated conditions Same principles of diagnosis and management apply as in patient without HIV
(after consideration of the above)
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Principles for management
Musculoskeletal syndromes in HIV may be unrelated to HIV infection
Treat the underlying cause if possibleRule out or correctly diagnosis infections
Probability of opportunistic infection depends on stage of HIVConsider HIV related medications in differential
diagnosisHigh threshold when using immunosuppressive drugs
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Acute monoarthritis
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Pitfalls Septic Joint
Acute Monoarthritis is a rheumatologic emergency
Infection may destroy a joint in 48 hours
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Septic ArthritisViralBacterial
Gram positive Gram negativeNeiseria (GC, MC)AnaerobicMycobacteria
Fungal
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Septic Arthritis (Risk factors)
Immunosuppression (drugs, HIV)Intravenous Drug AbuseAbnormal joint (increased risk for septic arthritis)
• OA• RA• Prosthesis
Remote infectious source
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Patient with monoarticular complaint
Complete history and Physical examination
Careful examreveals
poliarticular arthritis
Periarticularsyndrome
Tendinitis,bursitis, strain,
sprain,osteomyelitis, soft tissue rheumatism
True monoarticulararthritis
Significant trauma orfocal bone pain? Radiograph
Fracture,avulsion
OA, CPPD
Acute changes
Chronicchanges
Yes
Effusion or inflammation?
Arthrocentesis
Yes
CBC, ESR, physical exam
Ultrasound-guidedaspiration or
CT/MRI
Severesymptoms
No
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Arthrocentesis
Synovial fluidWBC > 5000
Acute inflammatoryarthritis
Synovial fluidWBC < 1000
Non-inflammatoryarthritis(OA, internal derangement)
Synovial fluidbloody
MRI
Arthroscopy
Internal derangement
Occult fracture,tumor, internalderangement
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Acute inflammatory arthritis(synovial fluid WBC > 5000/cm3)
Gram stain Infection
Crystalexam
Gout, CPPDr/o superinfection
CBC, ESR, RF,ANA, Ricketsae
Systemic toxicity?
Empiric antibioticsx24 hours, awaiting
cultures
Young: GC > staph >strepOld: staph > strep > GCImmunocompromised:Staph, gram-negative,other unusual organisms
CPPD, reactive arthritis,systemic rheumatic disease
Anti-inflammatory medication;Follow-up in 24-48 hours;Re-aspirate joint if worsens
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Infected joint in RA
Back
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TUBERCULOSISPott’s disease
Involvement of bone and discs with collapse of vertebrae
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TUBERCULOSISMonoarthritis and Tendosynovitis
Destructive joint diseaseMonitor for extra-articular TB