q4: clinical case conference on human immunodeficiency virus

Q4: Clinical Case Conference onHuman Immunodeficiency Virus

Chua, Kathleen S.

4. ENUMERATE RHEUMATIC CONDITIONS FOUND IN HIV-INFECTED INDIVIDUALS

Clinical Case Conference on Human Immunodeficiency Virus

U. A. Walker, A. Tyndall and T. Daikeler Rheumatic conditions in human immuno-deficiency virus infection Rheumatology 2008;47:952–959

Rheumatic conditions found in HIV-infected individuals

• HIV-associated arthritis– Nonerosive-oligoarthritis of the legs of unknown etiology – Found in up to 1% of patients– Usually self-limited and lasts less than 6 weeks

• Reiter's syndrome (reactive arthritis)– common in persons with HIV infection who are HLA-B27

positive– best treatment is HIV suppression and tumor necrosis factor

(TNF)-alpha antagonists.

• Septic arthritis– major joints affected are the sternoclavicular and leg joints.


Rheumatic conditions found in HIV-infected individuals

• Indinavir-associated hyperuricemia and arthralgia: – Indinavir has been implicated in HIV, but crystals were not

detected.

• Gout: – Hyperuricemia is common with HIV – Ritonavir boosting has been implicated

• Rhabdomyolysis: – May complicate primary HIV infection or complicate statin

use in patients receiving highly active antiretroviral therapy (HAART)


• HIV-associated polymyositis: – Polymyositis has been reported in as many as 2% to 7% of persons with HIV

infection– Muscle biopsy shows CD8 cell infiltrates and viral antigen.– HIV-associated polymyositis has been reported to be clinically and histologically

identical to idiopathic polymyositis, but has a good prognosis and responds well to immunosuppressive treatment.

• Zidovudine myopathy: – seen exclusively with zidovudine – characterized by muscle weakness and normal or slightly elevated creatine kinase

levels– Electron microscopy shows abnormal mitochondria that resolves with drug

discontinuation.

• Vasculitis: – This is described in early HIV disease in patients with high CD4 counts, as well as

later in patients with severe immunosuppression.– Biopsies show nonspecific neutrophilic or monocytic vascular inflammation and

often other clinical features, such as rash or peripheral neuropathy or both. – Some patients have cryoglobulinemia– Some have HIV-associated polyarteritis nodosa– Some have large-vessel complications, including aneurysms or strokes.


• Diffuse infiltrative lymphocytosis syndrome: – Prevalence in the HIV population is approximately 3%.– Present with bilateral painless parotid gland enlargement, lacrimal gland

enlargement, and sicca symptoms– The pathogenesis is thought to be an excessive response to HIV with CD8

lymphocytosis, and it may be associated with lymphoid interstitial pneumonia in up to 31%, or involvement of muscles or liver.

– HAART appears to be effective given that the incidence is decreasing

• Systemic lupus erythematosus: – This condition usually improves in patients with untreated HIV infection, which

fits the current concepts of the importance of CD4 cells in pathogenesis.– However, this can also be a component of immune reconstitution inflammatory

syndrome. – Systemic lupus erythematosus may also be the source of a false-positive

screening test for HIV, but not the confirmatory Western blot.

• Sarcoidosis: – When sarcoidosis coexists with HIV, most patients who are symptomatic have

CD4 counts exceeding 200 cells/µL, which is consistent with the current concept of the role of CD4 cell lymphocytes in the pathogenesis of granuloma formation.

– At present, most patients with active sarcoidosis have this as a result of immune reconstitution inflammatory syndrome.


q4: clinical case conference on human immunodeficiency virus

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