A. Introduction [1,2]

1. Up to 70% of patients with HIV infection / AIDS may develop muskuloskeltal symptoms
2. Majority will have arthalgias / arthritis
3. Symptoms usually worsen as CD4 counts decreased
4. Role of virus itself is not clear
5. Arthritis / Arthralgia
   1. Reiter Syndrome
   2. Psoriatic Arthritis
   3. Post-Infectious (reactive)
   4. Septic Arthritis
   5. AIDS-Associated Arthritis
   6. Non-specific polyarthralgias - may be >4% incidence
6. Myopathy
   1. Polymyositis - not uncommon
   2. Dermatomyositis - case reports only
   3. Drug Associated
7. Vasculitis
   1. Polyarteritis Type
   2. Mononeuritis Multiplex
   3. Temporal Arteritis / PMR
   4. Other - case reports (eg. eosinophilic vasculitis, granulomatous angiitis of CNS, etc)
8. Sicca Syndrome
   1. Xerophthalmia and Xerostomia
   2. Negative for ANA, SS-A or SS-B Abs
   3. May be prevalent in HLA-DRw52
9. Anti-Phospholipid Antibodies
   1. Relatively common in AIDS patients (may be >40% overall)
   2. Uncommon to develop thrombotic (or bleeding) complications
   3. May be associated with specific acute infections, espeically PCP
10. Not observed
    1. Rheumatoid Arthritis and SLE
    2. Crystal Induced Arthridites
    3. Ankylosing Spondylitis

B. Reiter Syndrome and HIV

1. Consistently increased incidence of Reiter Syndrome with HIV only in homosexuals
2. Prevalence [2,3]
   1. Initial studies suggested very high (~10%) prevalence [4]
   2. Probably related to high proportion of gay population at beginning of HIV epidemic
   3. Some patients had incomplete Reiter Syndrome (ie. reactive arthritis)
   4. Later studies, including prospective assessments, suggest 1-2% prevalence or even less
3. Symptoms
   1. Severe persistent oligoarticular arthritis
   2. Primarily affects large joints of lower extremities
   3. Sacroiliitis less common
   4. Urethritis, balanitis
   5. Conjunctivitis
   6. Painful oral ulcers
   7. Keratodermia blenorrhagicum - vesicles initially, become hyperkeratotic, then crust
4. Associated Organisms
   1. Organisms were rarely cultured from HIV+ patients with Reiter Syndrome
   2. Enterics: Shigella ssp. (usually S. flexneri), Salmonella, Yersinia, Campylobacter
   3. GU Tract: Chlamydia trachomatis, Ureaplasma urealyticum, N. gonorrhoea, S. pyogenes
5. HLA-B27
   1. ~75% of Caucaian patients with Reiter's Disease and HIV are B27+
   2. Very rare Black Reiter's patients to be B27+
6. Treatment
   1. NSAIDs are mainstay
   2. Other pain medications including narcotics may be needed
   3. Antiobiotics may be tried to eradicate chronic low grade infections (? precipitant)
   4. Steroids may be helpful

C. Psoriatic Arthritis [4]

1. Psoriasis may flare, or develop, with progressive HIV infection
   1. Most common form is severe polyarticular asymmeteric arthritis
   2. Sacroiliac and spine involvement not uncommon
   3. Nail destruction seen in severe cases
   4. Correlation high between skina and joint involvement
2. Psoriatic flares well documented in HIV Disease [5]
   1. Incidence of psoriasis with arthritis is 5-10 fold higher than expected in HIV
   2. Homosexuality does not appear to be a risk factor
   3. Symptoms progressed as CD4 count decreased
3. Treatment
   1. Clinical deterioration with methotrexate
   2. Patients have developed PCP and other infections commonly
   3. Caution with concommittant use of TMP/SMX (Bactrim®) and methotrexate
   4. Phototherapy usually leads to severe skin inflammation (eczema)
   5. Glucocorticoid therapy may be preferred over methotrexate
   6. Psoriasis may flare when glucocorticoids are discontinued
   7. Very slow taper usually required
   8. NSAIDs can provide symptomatic relief in some patients
   9. Cyclosporine may be very effective, used cautiously, in HIV+ psoriasis and arthritis [6]

D. HIV Associated Arthritis

1. Arthalgias and myalgias extremely common in HIV (>50% of patients over term of disease)
2. True arthritis is usu oligoarthritis
   1. Polyarthritis or monoarthritis may also occur
   2. Knees and/or ankles are commonly involved
3. Extreme pain is common, and may be initial presenting symptom of HIV disease
4. Highly variable synovial fluid joint counts
5. ANA, RF, HLA-B27 all negative
6. HIV has been cultured fromo synovial fluid and direct viral joint infection may occur

E. Polymyalgia Rheumatia and Giant Cell Arteritis [2]

1. Recent study suggests prevalence in HIV may be ~10X increased over expected
2. ESR was >60mm in the 3 cases and 2/3 cases had positive Biopsy
3. Treatment is prednisone, 40-80mg po qd with good response
   1. NSAIDs may improve HAs
   2. Zidovudine (AZT) may improve symptoms also
4. Immunizations should be updated
5. Diligent monitoring for infections (on prednisone)

F. Sicca Syndrome

1. Nearly all patients have Lyphadenopathy
2. Abnormal Schirmer Test (filter paper irritation on lower eyelid tear duct)
3. SSA and SSB Ab are usually Negative
4. Salivary gland biopsy shoes lymphocytic and plasmacytic infiltrates

References

1. Kay BR. 1989. Ann Intern Med. 111(2):158
2. Solinger AM and Hess EV. 1993. J Rheumatol. 20(4):678
3. Calabrese LH, Kelley DM, Myers A, et al. 1991. Arthritis Rheum. 34(3):257
4. Espinoza LR, Aguilar JL, Berman A, et al. 1989. Arthritis Rheum. 32(16):1615
5. Johnson TM, Duvic M, Rapini RP, Rios A. 1985. NEJM. 313:1415
6. Tourne L, Durez P, Van Vooren JP, et al. 1997. J Am Acad Dermatol. 37(3 Pt 1):501