Skeletal muscle involvement in human immunodeficiency virus (HIV)-infected patients in the era of highly active antiretroviral therapy (HAART)

The association between HIV infection, disability and lifestyle activity among middle-aged and older adults: an analytical cross-sectional study in Ivory Coast (the VIRAGE study)

INTRODUCTION

People living with HIV (PLWH) live longer and face new health challenges resulting from the confluence of chronic HIV infection and the natural effect of aging and comorbidities. However, there is a dearth of information on the long-term impact of HIV infection on the health and wellbeing of PLWH in sub-Saharan Africa. This research aimed to fill this gap by reporting on physical, functional and social outcomes among PLWH treated at a referral center in Abidjan, Ivory Coast, and comparing them with those of a control group.

METHODS

Body composition, functional capacity, sarcopenia, limitations in daily activities and social participation were assessed among 300 PLWH (aged ≥ 30 years) and 200 uninfected adults of similar age and sex. The associations between these outcomes and participants' socioeconomic characteristics, HIV history and physical activity level were assessed using generalized additive models adjusted for age and sex.

RESULTS

The median age was 51 years, and the median antiretroviral therapy duration was 15 years. Compared to controls, PLWH reported higher levels of physical activity (p < 0.0001). They had a lower muscle index (adjusted p < 0.0001) and grip strength (adjusted p < 0.0001) but achieved similar performance on the 6-min walk test (6MWT, p = 0.2). Among PLWH, physical activity level was positively associated with better performance in the 6MWT (p = 0.006) and greater hand grip strength (p = 0.04). The difference in physical performance according to the level of physical activity appeared mainly after the age of 60. PLWH reported similar rates of activity limitations (p = 0.8), lower depression levels and greater scores for social functioning (p = 0.02).

CONCLUSION

In this study, PLWH achieved high levels of physical activity, which may explain why they maintained good physical performance and social functioning despite having a higher risk of sarcopenia. These results have important implications for resource-limited health systems and show avenues for chronic care models.

TRIAL REGISTRATION

This study was registered on the ClinicalTrials.gov website (NCT05199831, first registration the 20/01/2022).

HIV-associated nemaline myopathy manifesting as bent spine syndrome

HIV-associated myopathies include HIV-associated polymyositis, inclusion body myositis, diffuse infiltrative lymphocytosis syndrome and sporadic late-onset nemaline myopathy (HIV-NM). HIV-NM typically manifests as a painless, progressive proximal and axial muscle weakness with characteristic histological findings of intracytoplasmic rods, or nemaline bodies, seen in atrophic muscle fibres. HIV-NM presents prior to or shortly after initiation of antiretroviral therapy (ART) and is treated with intravenous immunoglobulin, glucocorticoids or immunosuppression. We present a case of HIV-NM in a patient with well-controlled HIV on decades-long ART with progressive bent spine syndrome, or camptocormia. This case highlights the importance of considering HIV-associated myopathies such as HIV-NM in patients with HIV who present with musculoskeletal complaints.

Muscle strength/intensive care unit acquired weakness in COVID-19 and non-COVID-19 patients

BACKGROUND

Intensive care unit acquired weakness (ICU-AW) affects both coronavirus disease 19 (COVID-19) and non-COVID-19 patients. ICU-AW can result in a variety of consequences, including increased patient mortality.

AIMS

The current study aimed to compare muscle strength and ICU-AW in COVID-19 and non-COVID-19 patients.

STUDY DESIGN

This was a cross-sectional, descriptive-analytical pilot study.

METHODS

Fifteen conscious COVID-19 patients and 15 conscious non-COVID-19 patients admitted to the ICUs of a public hospital were selected by convenience sampling. Muscle strength in arms and legs was assessed by a hand-held dynamometer (HHD), and ICU-AW was measured with the medical research council sum score (MRC-SS) scale on the first, fourth, and seventh days of admission to ICUs.

RESULTS

The results showed that muscle strength in the arms and legs of the COVID-19 patients assessed by a HHD and MRC was significantly lower than that of non-COVID-19 patients. On the fourth day of ICU admission, 80% of the COVID-19 patients and 40% of the non-COVID-19 patients had ICU-AW. All COVID-19 patients and 86.8% of the non-COVID-19 patients had ICU-AW on the seventh day of ICU admission.

CONCLUSIONS

Decreased muscle strength and ICU-AW are more likely in COVID-19 patients who must stay in the ICU compared with non-COVID-19 patients.

RELEVANCE TO CLINICAL PRACTICE

Health systems should plan to provide rehabilitation facilities for COVID-19 patients and prevent prolonged complications of COVID-19.

Renal manifestations of syphilis

Syphilis is a sexually transmitted disease caused by spirochaete Treponema pallidum. The incidence of syphilis is rising across the globe. It has been described in the literature as a great imitator due to the vast range of clinical manifestations that can occur in the disease. Renal manifestations are rare but a feature of secondary syphilis. It can cause glomerulopathies, tubular pathology and vasculitic lesions in the kidney. Membranous nephropathy is the most commonly reported glomerular lesion associated with syphilis. With two recent cases of secondary membranous nephropathy due to syphilis, it is timely to review the current state of knowledge, and discuss the different renal manifestation of syphilis, its pathology and treatment options.

Infections of the Peripheral Nervous System

PURPOSE OF REVIEW

This article describes infections that affect the peripheral nervous system, including their clinical features, differential diagnoses, and treatments.

RECENT FINDINGS

Rates of pyomyositis have increased recently in the United States, possibly because of an increase in risk factors such as IV drug use, obesity, and diabetes. Other peripheral nervous system infections, such as diphtheria, have become more common in older patients secondary to a lack of revaccination or waning immunity. Although recommended treatment regimens for most infections remain unchanged over recent years, debate over the ideal dosing and route of administration continues for some infections such as tetanus and leprosy (Hansen disease).

SUMMARY

Infections of the peripheral nervous system are varied in terms of the type of infection, localization, and potential treatment. Nerve conduction studies and EMG can help determine localization, which is key to determining an initial differential diagnosis. It is important to recognize infections quickly to minimize diagnostic delays that could lead to patient morbidity and mortality.

Infective myositis

Myositis is inflammation especially of the voluntary muscles, characterized by localized or diffuse pain, tenderness on movement or palpation, swelling, and/or weakness. The two main categories of myositis include non-infectious and infectious. Infective myositis may be due to a wide variety of pathogens, including bacteria, fungi, viruses, and parasites. A brief account of the various pathogens causing infective myositis is discussed.

Neuromuscular involvement in COVID-19 critically ill patients

OBJECTIVE

Coronavirus disease 2019 (COVID-19) has a high incidence of intensive care admittance due to the severe acute respiratory syndrome (SARS). Intensive care unit (ICU)-acquired weakness (ICUAW) is a common complication of ICU patients consisting of symmetric and generalised weakness. The aim of this study was to determine the presence of myopathy, neuropathy or both in ICU patients affected by COVID-19 and whether ICUAW associated with COVID-19 differs from other aetiologies.

METHODS

Twelve SARS CoV-2 positive patients referred with the suspicion of critical illness myopathy (CIM) or polyneuropathy (CIP) were included between March and May 2020. Nerve conduction and concentric needle electromyography were performed in all patients while admitted to the hospital. Muscle biopsies were obtained in three patients.

RESULTS

Four patients presented signs of a sensory-motor axonal polyneuropathy and seven patients showed signs of myopathy. One muscle biopsy showed scattered necrotic and regenerative fibres without inflammatory signs. The other two biopsies showed non-specific myopathic findings.

CONCLUSIONS

We have not found any distinctive features in the studies of the ICU patients affected by SARS-CoV-2 infection.

SIGNIFICANCE

Further studies are needed to determine whether COVID-19-related CIM/CIP has different features from other aetiologies. Neurophysiological studies are essential in the diagnosis of these patients.

Respiratory Failure Secondary to Diaphragmatic Paralysis from Acute Exacerbation of Dermatomyositis

Dermatomyositis (DM) is an idiopathic inflammatory disorder that presents with proximal muscle weakness and typical DM skin changes. DM can involve other organs such as the lung, esophagus, and heart. Diaphragmatic muscle paralysis is an unrecognized clinical presentation of acute DM exacerbation. A 58-year-old man with a history of DM presented to the hospital after sustaining a cardiorespiratory arrest. Before arrest, he had been suffering from progressive dyspnea and muscle weakness. Immunosuppressive therapy of tacrolimus for DM was recently discontinued due to renal toxicity. Bedside ultrasound of the diaphragm while intubated revealed evidence of bilateral diaphragmatic paralysis. After extubation, supine and upright pulmonary function tests (PFT) and sniff test results strengthened the diagnosis of diaphragmatic paralysis. The patient was worked up for an acute DM exacerbation as the likely etiology of the severe diaphragmatic muscle weakness (diaphragmatic paralysis) and ventilatory failure. Skin and muscle biopsy confirmed the diagnosis of active DM. The patient was treated with high dose steroids and mycophenolate mofetil, following which he soon recovered.

Severe rhabdomyolysis and acute asymptomatic pancreatitis following the concomitant use of Biktarvy in the setting of hyperosmolar diabetic crisis

Biktarvy (bictegravir/emtricitabine/tenofovir alafemanide), which has been recently approved for the treatment of HIV, is a single-pill regimen that associates bictegravir and a novel integrase strand transfer inhibitor (INSTI) with a combination of two nucleoside reverse transcriptase inhibitors (NRTI) of emtricitabine and tenofovir alafemanide. Among treatment complications, rhabdomyolysis has been reported in association with some NRTI and INSTI but never with bictegravir. Acute pancreatitis has also been reported recently with another INSTI, dolutegravir. We report here a 62-year-old man with diabetes and HIV infection, and receiving Biktarvy for 1 month. He presented to the emergency department for muscular pain and fatigue. He was on treatment with Descovy (tenofovir alafenamide/emtricitabine) and Viramune (nevirapine) for 2 years but he recently asked for a regimen simplification. Severe rhabdomyolysis and acute pancreatitis were diagnosed. Although the aetiology of these events could be multifactorial, it cannot be ruled out that this episode could be linked to a potential side effect of bictegravir.

The spectrum of idiopathic inflammatory myopathies in South Africa

INTRODUCTION

There are many reports on idiopathic inflammatory myopathies (IIM) but little information from sub-Saharan Africa. We conducted a retrospective study of IIM in a multi-ethnic cohort seen at a single centre in Durban, South Africa.

METHOD

The study included patients who fulfilled the Bohan and Peter or European League Against Rheumatism/American College of Rheumatology criteria for IIM. The information recorded included demographic data, clinical findings, results of investigations, treatment and outcome. Patients with overlap myositis (OM) had myositis and criteria for another connective tissue disease.

RESULTS

There were 104 patients with IIM; 82.7% female and 70.2% African blacks. They included 41 (39.4%) with OM, 26 (25%) polymyositis (PM), 26 (25%) dermatomyositis (DM), six (5.8%) juvenile dermatomyositis and five (4.8%) cancer-associated myositis. Our patients had a younger mean age at diagnosis (36.8 ± 14.7 years) compared with 45-55 years in most other studies. Scleroderma-myositis overlap accounted for 26 (63.4%) of the patients with OM. Patients with OM were significantly younger than PM (p = 0.004) and DM (p = 0.044) and had lower, but not statistically significant, creatine kinase levels at diagnosis compared with PM (p = 0.052) and DM (p = 0.073). Interstitial lung disease was more common in OM (p = 0.001) and PM (p = 0.024) than DM. Oropharyngeal weakness was more common in DM than OM (p = 0.001) and PM (p = 0.032). African blacks were younger (p = 0.028) at diagnosis and had more cardiac abnormalities (p = 0.034) than Indians.

CONCLUSION

The spectrum of IIM in our cohort of mainly African blacks is similar to other studies, with OM being the most frequent subtype. Key Points • As there is limited information on idiopathic inflammatory myopathies (IIM) in sub-Saharan Africa, this study reports the spectrum of IIM in a South African cohort of predominantly African blacks. • Our patients were younger at diagnosis, and overlap myositis was the most common phenotype. • Comparisons with other studies show similarities in the manifestations of IIM.

Association Between Health-Related Quality of Life and Physical Functioning in Antiretroviral-Naive HIV-Infected Patients

Background:

Poor functional status can significantly affect Health-Related Quality of Life (HRQoL) of HIV patients. However, there is scarce information on the functional profile of such patients before starting antiretroviral therapy (ART).

Objective:

To estimate the association between health-related quality of life and physical functioning in Antiretroviral-Naive HIV-infected patients.

Methods:

We conducted a cross-sectional study with HIV-infected patients older than 18 years, and naïve to antiretroviral therapy. The patients were evaluated for functional profile by pulmonary function (forced vital capacity, forced expiratory volume at one second, and Tiffeneau index), handgrip strength, and six-minute walk test in a cross-sectional study. HRQoL was evaluated by the 36-Item Short-Form Health Survey and its Physical (PCS) and Mental (MCS) Component Summaries. Multiple linear regression analyses were used to evaluate the association of predictor variables with PCS and MCS scores.

Results:

We found lower HRQoL among females patients, with far below average impairment of mental health component. Both male and female patients presented lower 6MWD function test values. Patients with dynapenia were older than patients without it, presented lower PCS mean score, lower family income, poor 6 MWD function test, lower FVC, and lower FEV1 t. Multivariable logistic regression analyses showed that Grip Strength, age and family income were predictor variables for Physical component of HRQoL. Female gender and smoking habit were predictive for the mental component of HRQoL.

Conclusion:

HRQoL in HIV, drug-naïve patients is predicted by level of dynapenia, smoking, income and gender. Therefore, lifestyle changes and active exercising can help to improve HRQoL in such patients.

Functional status and physical impairments of adult patients infected with the human immunodeficiency virus admitted to hospital: a scoping review protocol

RESEARCH QUESTION/OBJECTIVE

The objectives of this scoping review are to describe the physical impairments and subsequent level of function of adult individuals infected with the human immunodeficiency virus (HIV) admitted to an acute care hospital, determine the outcome measures used by rehabilitation professionals when evaluating said impairments and level of function in the population of interest, and identify the rehabilitation interventions offered to individuals while in hospital as a means of addressing these physical impairments and individuals' functional status.Specifically, the research questions are:The current scoping review will comprehensively identify the physical impairments of people living with HIV when admitted to an acute care hospital and highlight the subsequent influence on their level of function as a means of emphasizing the disability present. Findings regarding the rehabilitation interventions offered could inform clinical practice as a means of mapping which interventions are offered to address the related physical impairments and thus highlight areas for future research.

Neuromuscular diseases associated with Human Immunodeficiency Virus infection

From the most common distal symmetric polyneuropathy (Bilgrami and O'Keefe, 2014) to the rare motor neuron diseases, HIV infection is associated with pathology at all levels of the peripheral nervous system. HIV infection can cause these conditions due to viral exposure itself, the resulting immune dysregulation, opportunistic infections found in untreated patients, and from the therapy used in treatment of the virus. Before the advent of antiretroviral therapy, 5 neuromuscular diseases associated with HIV often resulted from opportunistic infections. With advances in antiretroviral therapy, the etiologies of neuromuscular complications more frequently become the result of prolonged HIV exposure, comorbid diseases, and side effects of medications. In this article we review the literature on HIV associated neuromuscular diseases, emphasizing the more recent studies in the post antiretroviral era, but also reviewing conditions more prevalent in the pre antiretroviral era which continue to be seen in developing countries and resource poor areas. This discussion includes the following conditions: distal symmetric polyneuropathy, autonomic neuropathy, inflammatory demyelinating polyneuropathy, mononeuropathy, mononeuropathy multiplex, polyradiculopathies, myelopathy, myopathy, motor neuron disease, and antiretroviral treatment related conditions.

Rhabdomyolysis in an HIV cohort: epidemiology, causes and outcomes

Background

The Literature on rhabdomyolysis in the HIV-positive population is sparse and limited. We aimed to explore the incidence, patient characteristics, etiologies and outcomes of rhabdomyolysis in a cohort of HIV-positive patients identified through the Johns Hopkins HIV clinical registry between June 1992 and April 2014.

Methods

A retrospective analysis of 362 HIV-positive patients with non-cardiac CK elevation ≥1000 IU/L was performed. Both inpatients and outpatients were included. Incidence rate and potential etiologies for rhabdomyolysis were ascertained. The development of acute kidney injury (AKI, defined as doubling of serum creatinine), need for dialysis, and death in the setting of rhabdomyolysis were determined. Logistic regression was used to evaluate the association of peak CK level with the development of AKI.

Results

Three hundred sixty two cases of rhabdomyolysis were identified in a cohort of 7079 patients with a 38,382 person years follow-up time. The incidence rate was nine cases per 1000 person-years (95% CI: 8.5–10.5). Infection was the most common etiology followed by compression injury and drug/alcohol use. One-third of cases had multiple potential etiologies. AKI developed in 46% of cases; 20% of which required dialysis. Thirteen percent died during follow-up. After adjustment, AKI was associated with higher CK (OR 2.05 for each 1-log increase in CK [95% CI: 1.40–2.99]), infection (OR 5.48 [95% CI 2.65–11.31]) and higher HIV viral load (OR 1.22 per 1-log increase [95% CI: 1.03–1.45]).

Conclusion

Rhabdomyolysis in the HIV-positive population has many possible causes and is frequently multifactorial. HIV-positive individuals with rhabdomyolysis have a high risk of AKI and mortality.

Clinical, histological and radiological responses to methylprednisolone in HIV-associated rod myopathy

Skeletal muscle involvement as a neurologic manifestation in individuals with HIV is rare, especially as rod myopathy. We describe a 41-year-old male with HIV infection who presented progressive proximal muscle weakness and limb-girdle atrophy. A muscle magnetic resonance image showed bilateral fatty infiltration and post-contrast enhancement in the arm and thigh muscles. The muscle biopsy revealed intracytoplasmic aggregates with appearance of nemaline rod bodies with Gomori trichrome staining and electron microscopy in most fibers. The patient underwent six cycles of intravenous methylprednisolone pulses, presenting clinical improvement. Post-treatment muscle biopsy showed fewer nemaline bodies and muscle magnetic resonance image depicted a pronounced reduction of muscular edema. These findings corroborate that deposition of nemaline bodies in these patients might be related to an immune response triggered by the virus.

Clinical and symptomatological reflections: the fascial system

Every body structure is wrapped in connective tissue, or fascia, creating a structural continuity that gives form and function to every tissue and organ. Currently, there is still little information on the functions and interactions between the fascial continuum and the body system; unfortunately, in medical literature there are few texts explaining how fascial stasis or altered movement of the various connective layers can generate a clinical problem. Certainly, the fascia plays a significant role in conveying mechanical tension, in order to control an inflammatory environment. The fascial continuum is essential for transmitting muscle force, for correct motor coordination, and for preserving the organs in their site; the fascia is a vital instrument that enables the individual to communicate and live independently. This article considers what the literature offers on symptoms related to the fascial system, trying to connect the existing information on the continuity of the connective tissue and symptoms that are not always clearly defined. In our opinion, knowing and understanding this complex system of fascial layers is essential for the clinician and other health practitioners in finding the best treatment strategy for the patient.

Muscular weakness in individuals with HIV associated with a disorganization of the cortico-spinal tract: a multi-modal MRI investigation

Motor impairment is highly prevalent in HIV-infected patients. Here, we assess associations between peripheral muscular deficits as evaluated by the 5 sit-to-stand test (5STS) and structural integrity of the motor system at a central level. Eighty-six HIV-infected patients receiving combination antiretroviral therapy and with no major cerebral events, underwent an MRI scan and the 5STS. Out of 86 participants, forty presented a score greater than two standard deviations above mean normative scores calculated for the 5STS and were therefore considered as motor-impaired. MRI-structural cerebral parameters were compared to the unimpaired participants. Fractional Anisotropy (FA), Axial Diffusivity (AD) and Radial Diffusivity (RD), reflecting microstructural integrity, were extracted from Diffusion-Tensor MRI. Global and regional cerebral volumes or thicknesses were extracted from 3D-T1 morphological MRI. Whereas the two groups did not differ for any HIV variables, voxel-wise analysis revealed that motor-impaired participants present low FA values in various cortico-motor tracts and low AD in left cortico-spinal tract. However, they did not present reduced volumes or thicknesses of the precentral cortices compared to unimpaired participants. The absence of alterations in cortical regions holding motor-neurons might argue against neurodegenerative process as an explanation of White Matter (WM) disorganization.

Human immunodeficiency virus-associated obstructive lung diseases

In the era of effective antiretroviral therapy (ART), epidemiologic studies have found that persons infected with human immunodeficiency virus (HIV) have a higher prevalence and incidence of chronic obstructive pulmonary disease than HIV-uninfected persons. In comparison with HIV-uninfected persons and those with well-controlled HIV disease, HIV-infected persons with poor viral control or lower CD4 cell count have more airflow obstruction, a greater decline in lung function, and possibly more severe diffusing impairment. This article reviews the evidence linking HIV infection to obstructive lung disease, and discusses management issues related to the treatment of obstructive lung disease in HIV-infected patients.

Fatigue-related gene networks identified in CD(14)+ cells isolated from HIV-infected patients: part I: research findings

PURPOSE

Human immunodeficiency virus (HIV)-related fatigue (HRF) is multicausal and potentially related to mitochondrial dysfunction caused by antiretroviral therapy with nucleoside reverse transcriptase inhibitors (NRTIs).

METHODOLOGY

The authors compared gene expression profiles of CD14(+) cells of low versus high fatigued, NRTI-treated HIV patients to healthy controls (n = 5/group). The authors identified 32 genes predictive of low versus high fatigue and 33 genes predictive of healthy versus HIV infection. The authors constructed genetic networks to further elucidate the possible biological pathways in which these genes are involved. RELEVANCE FOR NURSING PRACTICE: Genes including the actin cytoskeletal regulatory proteins Prokineticin 2 and Cofilin 2 along with mitochondrial inner membrane proteins are involved in multiple pathways and were predictors of fatigue status. Previously identified inflammatory and signaling genes were predictive of HIV status, clearly confirming our results and suggesting a possible further connection between mitochondrial function and HIV. Isolated CD14(+) cells are easily accessible cells that could be used for further study of the connection between fatigue and mitochondrial function of HIV patients.

IMPLICATION FOR PRACTICE

The findings from this pilot study take us one step closer to identifying biomarker targets for fatigue status and mitochondrial dysfunction. Specific biomarkers will be pertinent to the development of methodologies to diagnosis, monitor, and treat fatigue and mitochondrial dysfunction.

External ophthalmoplegia in human immunodeficiency virus-infected patients receiving antiretroviral therapy

BACKGROUND

On rare occasions, patients infected with human immunodeficiency virus (HIV) can develop a disorder similar to chronic progressive external ophthalmoplegia (CPEO) while undergoing long-term treatment with antiretroviral therapy. Orbital imaging may help explain the pathogenesis of this abnormality.

METHODS

In this case series, 5 adult patients who presented with a CPEO-like disorder after more than 10 years of antiretroviral therapy and who underwent T1-weighted high-resolution magnetic resonance imaging (MRI) of the orbits and brain were retrospectively identified. Patients also were screened for acetylcholine receptor antibody levels.

RESULTS

All patients had bilateral external ophthalmoplegia and blepharoptosis. Acetylcholine receptor antibody titers were not increased. Brain MRI was unremarkable. Orbital MRI showed patchy bright signal inside the extraocular muscles that had conserved volume.

CONCLUSIONS

Patients with HIV under long-term antiretroviral therapy may develop functional abnormalities of extraocular muscles that are structurally normal in size, that is, changes are similar to those observed in the orbital MRIs of patients with CPEO. This constellation of signs and symptoms suggests a possible role of HIV disease or antiretroviral therapy in the CPEO-like syndrome observed in some HIV-infected individuals.

Neuromuscular manifestations of HIV/AIDS

The human immunodeficiency virus (HIV) epidemic, now entering its fourth decade, affects approximately 33 million people living in both developed and resource-limited countries. Neurological complications of the peripheral nervous system are common in HIV-infected patients, and neuromuscular pathology is associated with significant morbidity. Peripheral neuropathy is the most common neuromuscular manifestation observed in HIV/AIDS, and in the antiretroviral era, its prevalence has increased. The purpose of this review was to describe the clinical spectrum of neuromuscular disorders in the setting of HIV infection and to provide an approach to diagnosis and management.

The frequency of low muscle mass and its overlap with low bone mineral density and lipodystrophy in individuals with HIV--a pilot study using DXA total body composition analysis

As a result of the advances in antiretroviral therapy, the life span of human immunodeficiency virus (HIV)-infected patients has increased dramatically. Attendant to these effects are signs of premature aging with notable changes in the musculoskeletal system. Although changes in bone and fat distribution have been studied extensively, far less is known about changes in muscle. This study examined the extent of low muscle mass (LMM) and its relationship with low bone mineral density (BMD) and lipodystrophy (LD) in HIV-positive males. As such, HIV-positive males on therapy or treatment naive underwent dual-energy X-ray absorptiometry total body composition measurements. Appendicular lean mass/(height)2 and lowest 20% of residuals from regression analysis were used to define LMM. BMD criteria defined osteopenia/osteoporosis, and the percent central fat/percent lower extremity ratio defined LD. Several potential risk factors were assessed through chart review. Sixty-six males (57 with treatment and 9 treatment naive) volunteered. Treated individuals were older than naive (44 vs 34 yr) and had HIV longer (108 vs 14 mo). When definitions for sarcopenia (SP) in elderly individuals were applied, the prevalence of LMM was 21.9% and 18.8% depending on the definition used. Low BMD was present in 68.2% of participants. LD with a cutoff of 1.5 and 1.961 was present in 54.7% and 42.2% of participants, respectively. LMM and LD were negatively associated. In conclusion, this study shows that LMM is common in males with HIV and that SP affecting muscle function could be present in a substantial number of individuals. Future research needs to examine what impact decreased muscle mass and function has on morbidity, physical function, and quality of life in individuals with HIV.

The Relationship Between HIV Infection and Cardiovascular Disease

Over 30 million people are currently living with human immunodeficiency virus (HIV) infection, and over 2 million new infections occur per year. HIV has been found to directly affect vascular biology resulting in an increased risk of cardiovascular disease compared to uninfected persons. Although HIV infection can now be treated effectively with combination antiretroviral medications, significant toxicities such as hyperlipidemia, diabetes, and excess cardiovascular co-morbidity; as well as the potential for significant drug-drug interactions between HIV and cardiovascular medications, present new challenges for the management of persons infected with HIV. We first review basic principles of HIV pathogenesis and treatment and then discuss relevant clinical management strategies that will be useful for cardiologists who might be involved in the care of HIV infected patients.

Aspergillus-related myositis: a case report and review of the literature

OBJECTIVES

Infectious myositis can be a life-threatening condition. We describe the clinical presentation, diagnosis, treatment, and outcome of a patient with Aspergillus-related myositis and review the relevant literature on Aspergillus-related myositis.

METHODS

We report on a patient with acquired immunodeficiency syndrome who presented with Aspergillus myo-fasciitis, which was unusual because of its relapsing-remitting course and favorable outcome. We analyze the clinical features, diagnosis, and treatment of 9 additional patients identified through a PubMed literature review between 1964 and early 2010.

RESULTS

A 64-year-old human immunodeficiency virus positive African woman was hospitalized for a relapsing-remitting history of bilateral myo-fasciitis for more than 15 years. She had already undergone 3 previous muscle biopsies without definite diagnosis. A computed tomographic scan-guided biopsy revealed numerous septae hyphae with focal necrosis. Cultures yielded Aspergillus flavus as the underlying pathogen and the diagnosis of Aspergillus-related myo-fasciitis was finally made. On reviewing the literature, only 9 other cases have been described. However, no similar case with such a chronic and favorable course was reported.

CONCLUSIONS

As compared with the reported cases in the literature, our case is unusual because of its relapsing-remitting course for more than 15 years and favorable outcome. Our case emphasizes the difficulty of the diagnosis, and the importance of early and appropriate management of this rare myositis, which should be systematically evoked in patients with immune deficiency.

Paradoxical contractile properties in the knee extensors of HIV-infected men treated with antiretroviral therapy

We assessed contractile properties in the knee extensors of 18 men with the human immunodeficiency virus (HIV+) being treated with antiretroviral therapy (ART), and 9 healthy controls matched for age and body mass index. We found significant, divergent differences between groups with regard to force relaxation. Half-times of twitch relaxation were shorter (62.6 ± 5.4 ms vs. 48.9 ± 3.0 ms; p = 0.045) and maximum rates of torque relaxation were slower (0.47% ± 0.04%(s-)1 vs. 1.32% ± 0.10%(s-)1; p < 0.001) in HIV+ individuals. These preliminary findings suggest potential intramuscular impairments in HIV+ individuals on ART, perhaps because of interactions between calcium handling and mitochondrial dysfunction.

Comorbid HIV and myasthenia gravis: case report and review of the literature

A 27-year-old woman without known risk factors contracted HIV and was given highly active antiretroviral therapy in 2006. She subsequently developed myasthenia gravis (MG) that responded to treatment with pyridostigmine bromide and azathioprine. The medical literature, consisting primarily of case reports, indicates that MG occurs in relatively immunocompetent HIV-infected persons who generally present with mild MG symptoms. As such, we recommend a high index of suspicion for MG in HIV-infected patients presenting with fatigue and weakness, especially those receiving highly active antiretroviral therapy.

Nonbacterial myositis

Infectious myositis is defined as an infection of a skeletal muscle. Infectious myositis is most commonly caused by bacteria; however, a variety of viral, parasitic, and fungal agents may also cause myositis. The pathogenesis of nonbacterial infectious myositis is via direct or hematogenous infection of the musculature or immune mechanisms. Symptoms typically include muscular pain, tenderness, swelling, and/or weakness. The diagnosis of the specific microbe is often suggested by the presence of concordant clinical signs and symptoms, a detailed medical and travel history, and laboratory data. For example, immunocompromised hosts have a heightened risk of fungal myositis, whereas the presence of a travel history to an endemic location and/or eosinophilia may suggest a parasitic cause. Definitive diagnosis requires detecting the organism by specific laboratory testing including serologies, histopathology, and/or cultures. Treatment entails antimicrobial agents against the pathogen, with consideration for surgical drainage for focal purulent collections within the musculature.

Neurologic disease burden in treated HIV/AIDS predicts survival: a population-based study

BACKGROUND

Combination antiretroviral therapy (cART) has improved the survival of patients with HIV/AIDS but its impact remains uncertain on the changing prevalence and incidence of neurologic disorders with ensuing effects on mortality.

METHODS

The prevalence and incidence of neurologic disorders were examined in patients receiving active care in a regional HIV care program from 1998 to 2008. The mortality hazard ratio (HR) was calculated by Cox proportional hazard models with adjustment for demographic and clinical variables.

RESULTS

Of 1,651 HIV-infected patients assessed, 404 (24.5%) were identified as having one or more neurologic disorders, while 41% of AIDS-affected persons exhibited neurologic disease. Symptomatic distal sensory polyneuropathy (DSP, 10.0%) and HIV-associated neurocognitive disorder (HAND, 6.2%) represented the most prevalent disorders among 53 recognized neurologic disorders. Patients with at least one neurologic disorder exhibited higher mortality rates (17.6% vs 8.0%, p < 0.0001), particularly AIDS-related deaths (9.7% vs 3.2%, p < 0.0001), compared with those without neurologic disorders. The highest mortality HR was associated with opportunistic infections of CNS (HR 5.3, 95% confidence interval [CI] 2.5-11.2), followed by HAND (HR 3.1, 95% CI 1.8-5.3) and the presence of any neurologic disorder (HR 2.0, 95% CI 1.2-3.2). The risk of AIDS-related death with a neurologic disorder was increased by 13.3% per 100 cells/mm(3) decrement in blood CD4+ T-cell levels or by 39% per 10-fold increment in plasma viral load.

CONCLUSIONS

The burden and type of HIV-related neurologic disease have evolved over the past decade and despite the availability of cART, neurologic disorders occur frequently and predict an increased risk of death.

Polymyositis in African HIV-infected subjects

Polymyositis in HIV-infected subjects, clinically and pathologically resemble polymyositis in non-HIV-infected subjects. We report 14 consecutive HIV-associated polymyositis cases and compare specific features with 25 polymyositis cases seen over the same 6.5 year period. The HIV-polymyositis cases were all female and compared to the polymyositis cases were younger (median age 33 years, interquartile range (IQR) 29; 37 vs. 46 years, IQR 38; 52, p=0.002), and with 4-fold lower serum creatine kinase (CK) values (median 1158 vs. 5153IU/l; p=0.019). A definite clinical improvement on prednisone therapy was documented in eight HIV-polymyositis cases and one improved with anti-retroviral therapy alone. The recognition of HIV-polymyositis which is treatable, but may present with serum CK elevations less than twofolds above normal, is clinically relevant in sub-Saharan Africa where electromyography and muscle biopsies are not readily available.

Syrian hamster infected with Leishmania infantum: a new experimental model for inflammatory myopathies

Idiopathic inflammatory myopathies (IIMs) are inflammatory disorders of unknown origin. On the basis of clinical, histopathological, and immunological features, they can be differentiated into three major and distinct subsets: dermatomyositis; polymyositis; and inclusion-body myositis. Although a few animal models for IIM are currently available, they lack several characteristic aspects of IIMs. The aim of our study was to examine skeletal muscle involvement in an experimental animal model of visceral leishmaniasis, a disseminated infection caused by the protozoan parasite Leishmania infantum, and to compare features of associated inflammation with those of human IIM. Syrian hamsters infected intraperitoneally with amastigotes of L. infantum were killed at 3 or 4 months post-infection, and the skeletal muscles were studied. Focal inflammation was predominantly observed in the endomysium and, to a lesser extent, in perivascular areas. Degenerating muscle fibers were also found, as well as myonecrosis. Immunofluorescence with confocal laser scanning microscopy was used to characterize the phenotype of inflammatory infiltrates and the distribution of MHC class I and II in muscle biopsies. The infiltrating inflammatory cells consisted mainly of T cells, and CD8(+) T cells were found in non-necrotic muscle fibers that expressed MHC class I on the sarcolemma. In addition to T cells, several macrophages were present. The model we are proposing closely resembles polymyositis and may be useful in studying certain aspects of this disease such as the role of T cells in muscle inflammation and myocytotoxicity, while also providing novel therapeutic targets.

Prediction of cardiorespiratory fitness in older men infected with the human immunodeficiency virus: clinical factors and value of the six-minute walk distance

OBJECTIVES

To investigate factors related to cardiorespiratory fitness in older human immunodeficiency virus (HIV)-infected patients and to explore the utility of 6-minute walk distance (6-MWD) in measuring fitness.

DESIGN

Cross-sectional study in clinic-based cohort.

SETTING

Veterans Affairs Medical Center, Baltimore, Maryland.

PARTICIPANTS

Forty-three HIV-infected men, median age 57 (range 50-82), without recent acquired immunodeficiency syndrome-related illness and receiving antiretroviral (ARV) therapy.

MEASUREMENTS

Peak oxygen utilization (VO(2)peak) according to treadmill graded exercise testing, 6-MWD, grip strength, quadriceps maximum voluntary isometric contraction, cross-sectional area, muscle quality, and muscle adiposity.

RESULTS

There was a moderate correlation between VO(2)peak (mean +/- SD; 18.4 +/- 5.6 mL/kg per minute) and 6-MWD (514 +/- 91 m) (r=0.60, P<.001). VO(2)peak was lower in subjects with hypertension (16%, P<.01) and moderate anemia (hemoglobin 10-13 gm/dL; 15%, P=.09) than in subjects without these conditions. CD4 cell count (median 356 cells/mL, range 20-1,401) and HIV-1 viral load (84% nondetectable) were not related to VO(2)peak. Among muscle parameters, only grip strength was an independent predictor of VO(2)peak. Estimation of VO(2)peak using linear regression, including age, 6-MWD, grip strength, and hypertension as independent variables, explained 61% of the variance in VO(2)peak.

CONCLUSION

Non-AIDS-related comorbidity predicts cardiorespiratory fitness in older HIV-infected men receiving ARV therapy. The 6-MWD is a valuable measure of fitness in this patient population, but a larger study with diverse subjects is needed.

How citation distortions create unfounded authority: analysis of a citation network

OBJECTIVE

To understand belief in a specific scientific claim by studying the pattern of citations among papers stating it.

DESIGN

A complete citation network was constructed from all PubMed indexed English literature papers addressing the belief that beta amyloid, a protein accumulated in the brain in Alzheimer's disease, is produced by and injures skeletal muscle of patients with inclusion body myositis. Social network theory and graph theory were used to analyse this network.

MAIN OUTCOME MEASURES

Citation bias, amplification, and invention, and their effects on determining authority.

RESULTS

The network contained 242 papers and 675 citations addressing the belief, with 220,553 citation paths supporting it. Unfounded authority was established by citation bias against papers that refuted or weakened the belief; amplification, the marked expansion of the belief system by papers presenting no data addressing it; and forms of invention such as the conversion of hypothesis into fact through citation alone. Extension of this network into text within grants funded by the National Institutes of Health and obtained through the Freedom of Information Act showed the same phenomena present and sometimes used to justify requests for funding.

CONCLUSION

Citation is both an impartial scholarly method and a powerful form of social communication. Through distortions in its social use that include bias, amplification, and invention, citation can be used to generate information cascades resulting in unfounded authority of claims. Construction and analysis of a claim specific citation network may clarify the nature of a published belief system and expose distorted methods of social citation.

[Highly active antiretroviral therapy of neuro-AIDS. Side effects on the nervous system and interactions]

Highly active antiretroviral therapy (HAART) has increased the mean survival time in the AIDS stage to sometimes more than 10 years. Five different groups of antiretroviral medications are known, of which integrase inhibitors and CCR5 antagonists represent the newest and most modern substances. The long AIDS survival time implies that side effects and interactions become relatively more important and must be differentiated from the symptoms of HIV itself. Side effects of HAART concern the central and peripheral nervous system and the muscles. The neurotoxicity of the components in HAART varies considerably and depends on the substance itself. Knowledge of side effects and interactions of HAART with antiepileptics, antidepressants, and analgetics are essential for the treatment of patients with neuro-AIDS.

Acute encephalopathy and multi-organ involvement with rhabdomyolysis during primary HIV infection

An adolescent male developed encephalopathy and multiple organ involvement with rhabdomyolysis during primary HIV infection (PHI). All symptoms and signs resolved within a few days. Nineteen cases of central nervous system complications (other than aseptic meningitis) have been reported in PHI. These include encephalopathy, meningoencephalitis, acute disseminated encephalomyelitis, multiple sclerosis, myelopathy, and meningoradiculitis. Half of the patients died or suffered sequelae. Except in cases of multiple sclerosis, steroids were not of benefit. Initiation of antiretrovirals during PHI remains controversial. Rhabdomyolysis was reported in eight patients with PHI. All patients recovered. Primary HIV infection should be considered when the clinician faces patients with unexplained neurologic manifestations, rhabdomyolysis, or multiple organ involvement.

Antiretroviral therapy and central nervous system HIV type 1 infection

Central nervous system (CNS) human immunodeficiency virus type 1 (HIV-1) infection begins during primary viremia and continues throughout the course of untreated systemic infection. Although frequently accompanied by local inflammatory reactions detectable in cerebrospinal fluid (CSF), CNS HIV-1 infection usually is not clinically apparent. In a minority of patients, CNS HIV-1 infection evolves into encephalitis during the late stages of systemic infection, which compromises brain function and presents clinically as acquired immunodeficiency syndrome dementia complex (ADC). Combination antiretroviral therapy (ART) has had a major impact on all aspects of CNS HIV-1 infection and disease. In those with asymptomatic infection, ART usually effectively suppresses HIV-1 in CSF and markedly reduces the incidence of symptomatic ADC. In those presenting with ADC, ART characteristically prevents neurological progression and leads to variable, and at times substantial, recovery. Similarly, treatment has reduced CNS opportunistic infections. With better control of these severe disorders, attention has turned to the possible consequences of chronic silent infection and the issue of whether indolent, low-grade brain injury might require earlier treatment intervention.

Cystatin C and creatinine in an HIV cohort: the nutrition for healthy living study

BACKGROUND

Human immunodeficiency virus (HIV)-infected persons have an increased risk of chronic kidney disease (CKD). Serum creatinine level may underestimate the prevalence of CKD in subjects with decreased lean body mass or liver disease. Level of serum cystatin C, an alternative kidney function marker, is independent of lean body mass.

STUDY DESIGN

Cross-sectional.

SETTING & PARTICIPANTS

250 HIV-infected subjects on highly active antiretroviral therapy in the Nutrition for Healthy Living (NFHL) cohort; 2,628 National Health and Nutrition Examination Survey (NHANES) 2001-2002 subjects.

PREDICTORS & OUTCOMES

Comparison of serum creatinine levels in NFHL to those in NHANES subjects; comparison of CKD in NFHL subjects ascertained using serum creatinine versus cystatin C levels.

MEASUREMENTS

Standardized serum creatinine, serum cystatin C, glomerular filtration rate (GFR) estimated from serum creatinine and cystatin C levels.

RESULTS

Creatinine levels were lower in NFHL than NHANES subjects despite greater rates of hepatitis, diabetes, and drug use (mean difference, -0.18 mg/dL; P < 0.001 adjusted for age, sex, and race). Of NFHL subjects, only 2.4% had a creatinine-based estimated GFR less than 60 mL/min/1.73 m(2), but 15.2% had a cystatin-based estimated GFR less than 60 mL/min/1.73 m(2).

LIMITATIONS

GFR was estimated rather than measured. Other factors in addition to GFR may affect creatinine and cystatin C levels. Measurements of proteinuria were not available.

CONCLUSIONS

Serum creatinine levels may overestimate GFRs in HIV-infected subjects. Kidney disease prevalence may be greater than previously appreciated.