Proliferative Glomerulonephritis in Lupus Patients With Human Immunodeficiency Virus Infection: A Difficult Clinical Challenge

Antiretroviral Therapy Improves Acquired Immunodeficiency Syndrome with Systemic Lupus Erythematosus

A 35-year-old male was referred to our hospital with dysesthesia of the lower extremities that had begun six months earlier. A blood test revealed the presence of various antibodies, suggesting a collagen-related peripheral neuropathy. However, a history of repeated shingles and sex with males was noted, and the patient was tested for and diagnosed with human immunodeficiency virus (HIV) infection. Based on the manifestations and laboratory data, including the results of immunological and urinary tests, he was further diagnosed with concomitant systemic lupus erythematosus (SLE). The activity of SLE improved with antiretroviral therapy. There is currently no established treatment for AIDS complicated with SLE. Indeed, because HIV treatment involves the activation of immune function and SLE treatment involves immunosuppression, any treatments for the two conditions would be in conflict. It is thus necessary to select a treatment strategy based on the condition of the individual patient. In addition, because HIV infection is relatively rare in Japan compared to other countries, rheumatologists in Japan must keep HIV infection in mind as a differential diagnosis for autoimmune diseases.

Viral Infections and Systemic Lupus Erythematosus: New Players in an Old Story

A causal link between viral infections and autoimmunity has been studied for a long time and the role of some viruses in the induction or exacerbation of systemic lupus erythematosus (SLE) in genetically predisposed patients has been proved. The strength of the association between different viral agents and SLE is variable. Epstein-Barr virus (EBV), parvovirus B19 (B19V), and human endogenous retroviruses (HERVs) are involved in SLE pathogenesis, whereas other viruses such as Cytomegalovirus (CMV) probably play a less prominent role. However, the mechanisms of viral-host interactions and the impact of viruses on disease course have yet to be elucidated. In addition to classical mechanisms of viral-triggered autoimmunity, such as molecular mimicry and epitope spreading, there has been a growing appreciation of the role of direct activation of innate response by viral nucleic acids and epigenetic modulation of interferon-related immune response. The latter is especially important for HERVs, which may represent the molecular link between environmental triggers and critical immune genes. Virus-specific proteins modulating interaction with the host immune system have been characterized especially for Epstein-Barr virus and explain immune evasion, persistent infection and self-reactive B-cell "immortalization". Knowledge has also been expanding on key viral proteins of B19-V and CMV and their possible association with specific phenotypes such as antiphospholipid syndrome. This progress may pave the way to new therapeutic perspectives, including the use of known or new antiviral drugs, postviral immune response modulation and innate immunity inhibition. We herein describe the state-of-the-art knowledge on the role of viral infections in SLE, with a focus on their mechanisms of action and potential therapeutic targets.

Diffuse connective tissue disorders in HIV-infected patients

Background:

Human immunodeficiency virus (HIV) infection has been associated with various autoimmune disorders.

Aim:

To review the spectrum of diffuse connective tissue disorders (dCTD) in HIV-infected patients, in the context of highly active anti-retroviral therapy.

Methods:

Electronic search of the literature was performed using the terms HIV, AIDS, autoimmune, rheumatic/rheumatological, immune reconstitution inflammatory syndrome, Systemic Lupus Erythematosus, Diffuse Infiltrative Lymphocytosis Syndrome, Sjogren’s syndrome, vasculitis, Behçet’s disease, cryoglobulins, Henoch-Schönlein purpura, and antiphospholipid syndrome.

Results:

We reviewed the clinical manifestations, natural history and treatment of dCTDs, since the implementation of Highly Active Anti-Retroviral Therapy (HAART), and the emergence of new pathogenic mechanisms, such as the immune reconstitution inflammatory syndrome.

Conclusions:

Caution in differentiating clinical and laboratory findings of dCTDs from non-specific manifestations of acute and chronic HIV infection is warranted due to the common presentation. Patients with chronic infection and access to HAART have a normal life expectancy and dCTDs, although rare, must be correctly addressed. HAART alone or combined with immunosuppressive therapy result in favourable outcomes.

Human immunodeficiency virus in a cohort of systemic lupus erythematosus patients

BACKGROUND

Systemic lupus erythematosus (SLE) and acquired immunodeficiency syndrome (AIDS) share many clinical manifestations and laboratory findings, therefore, concomitant diagnosis of SLE and human immunodeficiency virus (HIV) can be challenging.

METHODS

Prospective cohort with 602 patients with SLE who attended the Rheumatology Clinic of the Hospital de Clínicas de Porto Alegre since 2000. All patients were followed until 01 May 2015 or until death, if earlier. Demographic, clinical and laboratory data were prospectively collected.

RESULTS

Out of the 602 patients, 11 presented with the diagnosis of AIDS (1.59%). The following variables were significantly more prevalent in patients with concomitant HIV and SLE: neuropsychiatric lupus (10.9% vs. 36.4%; p = 0.028) and smoking (37.6% vs. 80%; p = 0.0009) while malar rash was significantly less prevalent in this population (56% vs. 18.2%; p = 0.015). Nephritis (40.5% vs. 63.6%; p = 0.134) and hemolytic anemia (28.6% vs. 54.5%; p = 0.089) were more prevalent in SLE patients with HIV, but with no statistical significance compared with SLE patients without HIV. The SLICC damage index median in the last medical consultation was significantly higher in SLE patients with HIV (1 vs. 2; p = 0,047).

CONCLUSIONS

Our patients with concomitant HIV and SLE have clinically more neuropsychiatric manifestations. For the first time, according to our knowledge, higher cumulative damage was described in lupus patients with concomitant HIV infection. Further studies are needed to elucidate this complex association, its outcomes, prognosis and which therapeutic approach it's best for each case.

Assessment and management of musculoskeletal disorders among patients living with HIV

HIV is a global pandemic. However, anti-retroviral therapy has transformed the prognosis and, providing compliance is good, a normal life expectancy can be anticipated. This has led to increasing numbers of people with chronic prevalent, treated infection living to older ages. Musculoskeletal pain is commonly reported by HIV patients and, with resumption of near-normal immune function, HIV-infected patients develop inflammatory rheumatic diseases that require assessment and management in rheumatology clinics. Moreover, it is becoming apparent that avascular necrosis and osteoporosis are common comorbidities of HIV. This review will contextualize the prevalence of musculoskeletal symptoms in HIV, informed by data from a UK-based clinic, and will discuss the management of active inflammatory rheumatic diseases among HIV-infected patients taking anti-retroviral therapy, highlighting known drug interactions.

Evolving spectrum of HIV-associated rheumatic syndromes

At the end of 2013, 35 million people worldwide were infected with HIV. The prognosis of HIV has been transformed by combination antiretroviral therapy (cART). Providing compliance is good, the use of cART has normalised the life expectancy of HIV-infected people leading to a growing population of people with chronic infection. Management of HIV patients has therefore needed to adapt in order to not only control viral activity but also manage long-term complications of HIV and cART. Rheumatological manifestations of HIV were first described in 1989. Since then, there have been case reports, case series and epidemiological studies describing different clinical manifestations of HIV in the musculoskeletal system. This review will encompass musculoskeletal pain, fibromyalgia, systemic lupus erythematosus (SLE) and inflammatory arthritis in HIV. We will aim to report on the prevalence of these conditions and the risk factors, explore the impact of the virus on the clinical presentations and discuss implications for diagnosis and management.

HIV-associated juvenile systemic sclerosis: a case report

INTRODUCTION

Autoimmune connective tissue diseases occur in HIV-infected persons though with a lower frequency than in the general population. However, since the advent of highly active antiretroviral therapy (HAART), the spectrum of autoimmune diseases reported in HIV-infected patients has increased.

OBJECTIVE

To describe the occurrence and management of systemic sclerosis in a HIV-infected child.

METHODS

A case report of HIV-associated systemic sclerosis and a review of the literature on previously published cases.

RESULTS

A nine-year-old girl presented with HIV-associated systemic sclerosis complicated with interstitial lung disease and oesophageal dysmotility. She was treated with intravenous cyclophosphamide with good response on her skin scores and modest improvement in lung function parameters. She manifested no deterioration in her clinical status. However, she developed mild lymphopaenia following the treatment with cyclophosphamide.

CONCLUSION

We have described the rare occurrence of HIV infection and systemic sclerosis in a nine-year-old girl. She received cyclophosphamide for management of the systemic manifestations of SSc and did not manifest any major adverse events except mild lymphopaenia. Thus, though cyclophosphamide appeared safe in the management of HIV-associated systemic sclerosis, close monitoring of lymphocyte and CD4 counts should be done in such patients.

Autoimmune diseases in HIV-infected patients: 52 cases and literature review

OBJECTIVES

1) To describe autoimmune diseases (AD) in HIV-infected people; and 2) to perform a literature review concerning this issue.

DESIGN

52 HIV-infected patients that presented an AD in 14 medical departments in Paris and Ile-de-France area were retrospectively included in this study.

RESULTS

The ADs were vasculitis (11), immune cytopenias (8), rheumatic diseases (8), lupus (7), sarcoidosis (7), thyroid diseases (6), hepatic diseases (5), and antiphospholipid syndrome (4). Four patients presented 2 ADs. In 5 patients the AD preceded HIV infection, in 14 HIV infection was diagnosed at the same time as the AD and 34 were HIV-infected when they developed an AD. 40 ADs (80%) occurred in patients with a CD4 T lymphocyte count of more than 200/mm(3). Cases of autoimmune hemolytic anemia occurred only in patients severely immunodepressed. In five patients (a vasculitis case, a sarcoidosis case, three thyroid disease cases) the AD presented as a form of immune restoration inflammatory syndrome (IRIS). Some ADs allowed HIV-infection diagnosis at a stage of moderate immune deficiency (vasculitis, antiphospholipid syndrome, immune thrombocytopenia). 37 patients received immunosuppressant treatments with good tolerance. These results confirm in a large series of patients previous data concerning autoimmune diseases occurrence in HIV-infected people.

CONCLUSION

In the HAART era, when HIV-infected people are treated more and more early, autoimmune diseases can occur, mainly at the phase of immunological recovery. HIV infection should not limit immunosuppressant treatment use.

Comparison of risk factors and outcomes in HIV immune complex kidney disease and HIV-associated nephropathy

BACKGROUND AND OBJECTIVES

HIV-associated nephropathy (HIVAN) is well described, but the clinical features of a group of renal pathologies characterized by Ig or immune complex depositions referred to as HIV-associated immune complex kidney disease (HIVICK) have not been well established. The objective of this study is to assess risk factors for HIVICK compared with contemporaneous control participants.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A nested case-control study of 751 HIV-infected patients followed from January 1996 to June 2010 was conducted. Groups were compared using the chi-squared test or rank-sum analysis. Conditional logistic regression was used to estimate odds ratios (ORs) for HIVICK. Incidences of overall ESRD and with/without combined antiretroviral therapy (cART) exposure were calculated.

RESULTS

HIVICK patients were predominantly African American (92%). Compared with matched controls, patients with HIVICK were more likely to have HIV RNA >400 copies/ml (OR, 2.5; 95% confidence interval [95% CI], 1.2 to 5.2), diabetes (OR, 2.8; 95% CI, 1.1 to 6.8), and hypertension (OR, 2.3; 95% CI, 1.2 to 4.5). Compared with HIVAN, patients with HIVICK had more antiretroviral therapy exposure, lower HIV viral loads, and higher CD4 and estimated GFR. ESRD was less common in the HIVICK versus the HIVAN group (30% versus 82%; P<0.001), and the use of cART was not associated with ESRD in HIVICK patients (25% versus 26; P=0.39).

CONCLUSIONS

HIVICK was predominantly observed in African-American patients and associated with advanced HIV disease. ESRD incidence is lower in HIVICK patients compared with those with HIVAN. Unlike HIVAN, cART use was not associated with the incidence of ESRD in HIVICK.

Systemic lupus erythematosus and HIV infection: a whimsical relationship. Reports of two cases and review of the literature

Systemic lupus erythematosus (SLE) is rarely reported in association with HIV infection. We describe two unpredictable cases and provide a review of the literature. Retrospective analysis of the medical records of two HIV-infected patients diagnosed with SLE and admitted at Luigi Sacco Hospital (Milano, Italy). Search of the literature from 1981 to 2012 and review of the cases reported. Case 1: a 32-year-old HIV-infected African woman who developed a SLE flare after re-introduction of antiretroviral therapy (ART). The flare was characterized by bullous skin eruption and membranous glomerulonephritis. Case 2: a 44-year-old Caucasian woman, admitted to our hospital because of lacunar stroke: HIV infection and SLE were simultaneously diagnosed.

LITERATURE

55 cases of SLE in the setting of HIV infection were reported. Forty-five patients met the requirements of the American College of Rheumatology for the diagnosis of SLE. The diagnosis of SLE preceded HIV infection in six patients. On the contrary, in 29 patients, HIV infection was reported before SLE. Median CD4+ count at SLE diagnosis was 361 cells/μl. A SLE manifestation following ART immune recovery was documented in 18.2% of the cases. On the contrary, the progression of HIV infection paralleled with SLE remission in 22.5% of the patients. The study shows that an autoimmune disease such as SLE can occur despite the loss of immunocompetence caused by HIV infection. Moreover, SLE and HIV infection influence each other possibly through immunologic mechanisms determining awkward manifestations.

Chronic kidney disease associated with perinatal HIV infection in children and adolescents

BACKGROUND

This study describes the incidence, clinical and demographic characteristics, and spectrum of chronic kidney disease (CKD) in youths with perinatal HIV-1 infection.

METHODS

Retrospective analysis between May 1993 and December 2006 of subjects with renal disease followed in the Pediatric AIDS Clinical Trials Group 219/219C multicenter study examining the long-term consequences of perinatal HIV infection. Diagnosis confirmation was made utilizing a questionnaire mailed to research sites. Participants with CKD of other etiology than HIV were excluded. Outcome measures were biopsy-diagnosed CKD and, in the absence of biopsy, HIV-associated nephropathy (HIVAN) using established clinical criteria.

RESULTS

Questionnaires on 191 out of 2,102 participants identified 27 cases of CKD: 14 biopsy-diagnosed and 6 clinical cases of HIVAN, and 7 biopsy-diagnosed cases of immune complex-mediated kidney disease (lupus-like nephritis, 3; IgA nephropathy, 2; membranous nephropathy, 2). Incidence rates for CKD associated with HIV in pre-highly active antiretroviral therapy (HAART) (1993-1997) and HAART (1998-2002, 2003-2006) eras were 0.43, 2.84, and 2.79 events per 1,000 person years respectively. In multivariate analysis, black race and viral load ≥100,000 copies/mL (rate ratios 3.28 and 5.05, p ≤ 0.02) were associated with CKD.

CONCLUSIONS

A variety of immune complex-mediated glomerulonephritides and HIVAN occurs in this population. Black race and uncontrolled viral replication are risk factors for CKD associated with HIV.