A. Introduction [1,2]
- Up to 70% of patients with HIV infection / AIDS may develop muskuloskeltal symptoms
- Majority will have arthalgias / arthritis
- Symptoms usually worsen as CD4 counts decreased
- Role of virus itself is not clear
- Arthritis / Arthralgia
- Reiter Syndrome
- Psoriatic Arthritis
- Post-Infectious (reactive)
- Septic Arthritis
- AIDS-Associated Arthritis
- Non-specific polyarthralgias - may be >4% incidence
- Myopathy
- Polymyositis - not uncommon
- Dermatomyositis - case reports only
- Drug Associated
- Vasculitis
- Polyarteritis Type
- Mononeuritis Multiplex
- Temporal Arteritis / PMR
- Other - case reports (eg. eosinophilic vasculitis, granulomatous angiitis of CNS, etc)
- Sicca Syndrome
- Xerophthalmia and Xerostomia
- Negative for ANA, SS-A or SS-B Abs
- May be prevalent in HLA-DRw52
- Anti-Phospholipid Antibodies
- Relatively common in AIDS patients (may be >40% overall)
- Uncommon to develop thrombotic (or bleeding) complications
- May be associated with specific acute infections, espeically PCP
- Not observed
- Rheumatoid Arthritis and SLE
- Crystal Induced Arthridites
- Ankylosing Spondylitis
B. Reiter Syndrome and HIV
- Consistently increased incidence of Reiter Syndrome with HIV only in homosexuals
- Prevalence [2,3]
- Initial studies suggested very high (~10%) prevalence [4]
- Probably related to high proportion of gay population at beginning of HIV epidemic
- Some patients had incomplete Reiter Syndrome (ie. reactive arthritis)
- Later studies, including prospective assessments, suggest 1-2% prevalence or even less
- Symptoms
- Severe persistent oligoarticular arthritis
- Primarily affects large joints of lower extremities
- Sacroiliitis less common
- Urethritis, balanitis
- Conjunctivitis
- Painful oral ulcers
- Keratodermia blenorrhagicum - vesicles initially, become hyperkeratotic, then crust
- Associated Organisms
- Organisms were rarely cultured from HIV+ patients with Reiter Syndrome
- Enterics: Shigella ssp. (usually S. flexneri), Salmonella, Yersinia, Campylobacter
- GU Tract: Chlamydia trachomatis, Ureaplasma urealyticum, N. gonorrhoea, S. pyogenes
- HLA-B27
- ~75% of Caucaian patients with Reiter's Disease and HIV are B27+
- Very rare Black Reiter's patients to be B27+
- Treatment
- NSAIDs are mainstay
- Other pain medications including narcotics may be needed
- Antiobiotics may be tried to eradicate chronic low grade infections (? precipitant)
- Steroids may be helpful
C. Psoriatic Arthritis [4]
- Psoriasis may flare, or develop, with progressive HIV infection
- Most common form is severe polyarticular asymmeteric arthritis
- Sacroiliac and spine involvement not uncommon
- Nail destruction seen in severe cases
- Correlation high between skina and joint involvement
- Psoriatic flares well documented in HIV Disease [5]
- Incidence of psoriasis with arthritis is 5-10 fold higher than expected in HIV
- Homosexuality does not appear to be a risk factor
- Symptoms progressed as CD4 count decreased
- Treatment
- Clinical deterioration with methotrexate
- Patients have developed PCP and other infections commonly
- Caution with concommittant use of TMP/SMX (Bactrim®) and methotrexate
- Phototherapy usually leads to severe skin inflammation (eczema)
- Glucocorticoid therapy may be preferred over methotrexate
- Psoriasis may flare when glucocorticoids are discontinued
- Very slow taper usually required
- NSAIDs can provide symptomatic relief in some patients
- Cyclosporine may be very effective, used cautiously, in HIV+ psoriasis and arthritis [6]
D. HIV Associated Arthritis
- Arthalgias and myalgias extremely common in HIV (>50% of patients over term of disease)
- True arthritis is usu oligoarthritis
- Polyarthritis or monoarthritis may also occur
- Knees and/or ankles are commonly involved
- Extreme pain is common, and may be initial presenting symptom of HIV disease
- Highly variable synovial fluid joint counts
- ANA, RF, HLA-B27 all negative
- HIV has been cultured fromo synovial fluid and direct viral joint infection may occur
E. Polymyalgia Rheumatia and Giant Cell Arteritis [2]
- Recent study suggests prevalence in HIV may be ~10X increased over expected
- ESR was >60mm in the 3 cases and 2/3 cases had positive Biopsy
- Treatment is prednisone, 40-80mg po qd with good response
- NSAIDs may improve HAs
- Zidovudine (AZT) may improve symptoms also
- Immunizations should be updated
- Diligent monitoring for infections (on prednisone)
F. Sicca Syndrome
- Nearly all patients have Lyphadenopathy
- Abnormal Schirmer Test (filter paper irritation on lower eyelid tear duct)
- SSA and SSB Ab are usually Negative
- Salivary gland biopsy shoes lymphocytic and plasmacytic infiltrates
References
- Kay BR. 1989. Ann Intern Med. 111(2):158

- Solinger AM and Hess EV. 1993. J Rheumatol. 20(4):678

- Calabrese LH, Kelley DM, Myers A, et al. 1991. Arthritis Rheum. 34(3):257

- Espinoza LR, Aguilar JL, Berman A, et al. 1989. Arthritis Rheum. 32(16):1615
- Johnson TM, Duvic M, Rapini RP, Rios A. 1985. NEJM. 313:1415

- Tourne L, Durez P, Van Vooren JP, et al. 1997. J Am Acad Dermatol. 37(3 Pt 1):501
