Combined autoimmune disease in a patient with AIDS

Unusual Presentation of Relapsing Polychondritis in a Patient with Human Immunodeficiency Virus and Reactive Arthritis

Patient: Female, 58-year-old

Final Diagnosis: Relapsing polychondritis

Symptoms: Ear pain • eye pain

Medication: —

Clinical Procedure: —

Specialty: Rheumatology

Immune reconstitution inflammatory syndrome in HIV-infected patients receiving antiretroviral therapy : pathogenesis, clinical manifestations and management

The use of antiretroviral therapy (ART) to treat HIV infection, by restoring CD4+ cell count and immune function, is associated with significant reductions in morbidity and mortality. Soon after ART initiation, there is a rapid phase of restoration of pathogen-specific immunity. In certain patients, this results in inflammatory responses that may result in clinical deterioration known as 'the immune reconstitution inflammatory syndrome' (IRIS). IRIS may be targeted at viable infective antigens, dead or dying infective antigens, host antigens, tumour antigens and other antigens, giving rise to a heterogeneous range of clinical manifestations. The commonest forms of IRIS are associated with mycobacterial infections, fungi and herpes viruses. In most patients, ART should be continued and treatment for the associated condition optimized, and there is anecdotal evidence for the use of corticosteroids in patients who are severely affected. In this review, we discuss research relating to pathogenesis, the range of clinical manifestations, treatment options and prevention issues.

Relapsing polychondritis in HIV-infected patients: a report of two cases

Relapsing polychondritis is a rare autoimmune disease characterized by inflammation and degeneration of cartilaginous tissue. We describe the first reported cases of relapsing polychondritis in patients with human immunodeficiency virus (HIV) and no associated connective tissue diseases. The relationship between autoimmune and HIV diseases is complex and unclear. Treatment of HIV disease with antiretroviral therapy and subsequent immune restoration may lead to the development of autoimmune diseases in genetically susceptible individuals.

Immune restoration disease after antiretroviral therapy

Suppression of HIV replication by highly active antiretroviral therapy (HAART) often restores protective pathogen-specific immune responses, but in some patients the restored immune response is immunopathological and causes disease [immune restoration disease (IRD)]. Infections by mycobacteria, cryptococci, herpesviruses, hepatitis B and C virus, and JC virus are the most common pathogens associated with infectious IRD. Sarcoid IRD and autoimmune IRD occur less commonly. Infectious IRD presenting during the first 3 months of therapy appears to reflect an immune response against an active (often quiescent) infection by opportunistic pathogens whereas late IRD may result from an immune response against the antigens of non-viable pathogens. Data on the immunopathogenesis of IRD is limited but it suggests that immunopathogenic mechanisms are determined by the pathogen. For example, mycobacterial IRD is associated with delayed-type hypersensitivity responses to mycobacterial antigens whereas there is evidence of a CD8 T-cell response in herpesvirus IRD. Furthermore, the association of different cytokine gene polymorphisms with mycobacterial or herpesvirus IRD provides evidence of different pathogenic mechanisms as well as indicating a genetic susceptibility to IRD. Differentiation of IRD from an opportunistic infection is important because IRD indicates a successful, albeit undesirable, effect of HAART. It is also important to differentiate IRD from drug toxicity to avoid unnecessary cessation of HAART. The management of IRD often requires the use of anti-microbial and/or anti-inflammatory therapy. Investigation of strategies to prevent IRD is a priority, particularly in developing countries, and requires the development of risk assessment methods and diagnostic criteria.

Relapsing polychondritis

SUMMARY

Relapsing polychondritis is a unique, rare autoimmune disorder in which the cartilaginous tissues are the primary targets of destruction but the immune damage can spread to involve noncartilaginous tissues like the kidney, blood vessels, and so forth. The manifestations of the disease can take many different forms and the pathogenesis is still unclear. It may occur in a primary form or it may be associated with other disease states. This article summarizes important aspects of the disease with a focus on recent information regarding clinical manifestations, disease associations, pathogenesis, and advances in therapeutics.

Rheumatic manifestations of human immunodeficiency virus

Since July 1983, various rheumatic, musculoskeletal, or other immune disorders characterized by dysregulation have been associated with HIV and AIDS. Infections occur, but with a lower frequency than expected in a patient population with a disorder primarily characterized by significant cellular immune deficiencies. Reactive arthritis, psoriatic arthritis, acute nonspecific arthritis, Sjögren syndrome, and inflammatory myositis have been reported. The initial reports of "acute painful joints," however, have not maintained prominence in the literature. A review of the literature over the past several years has reinforced the perception that the initial excitement over a possible association between HIV and AIDS and rheumatic or definable autoimmune disorders remains limited to a small segment of illnesses dominated by the reactive arthritidies.