Retroviral-associated vasculitis of the nervous system

Intracranial Aneurysms Involving Circle of Willis in a Child with Human Immunodeficiency Virus Associated Vasculitis- A Rare Case Report

Intracranial Arterial Aneurysms (IAAs) are relatively rare in paediatric population and they account for at least 10%-15% of haemorrhagic strokes which occur during the first two decades of life. Here we present a unique and unusual case of Human Immunodeficiency Virus (HIV) infected child who presented with intracranial aneurysms with formation of collaterals and vasculopathy, demonstrating low viral count despite receiving adequate antiretroviral treatment. Intracranial vascular involvement, their complications and its incidence in these patients may become increasingly common as the management of human immunodeficiency virus infection continues to improve and afflicted patients survive for longer periods because of advancement in the antiretroviral treatment. Diagnosing aneurysm of cerebral circulation needs high degree of suspicion and correlation between clinical and radiological findings.

Plasma klotho levels were inversely associated with subclinical carotid atherosclerosis in HIV-infected patients receiving combined antiretroviral therapy

Combined antiretroviral therapy (cART) has significantly improved the survival rate in HIV-infected individuals, but it contributes to the development of various metabolic complications. Klotho is a novel antiaging gene that encodes a protein with pleiotropic functions, including an emerging role in cardiovascular disease (CVD). The protective effect of higher plasma klotho levels against CVD was recently observed in non-HIV-infected adults. We aimed to assess whether plasma-secreted α-klotho is associated with subclinical carotid atherosclerosis in HIV-infected patients receiving cART. We prospectively examined the association of circulating plasma α-klotho in 120 HIV-infected patients who had received cART for ≥6 months with intima-media thickness (IMT) in the carotid artery and other metabolic variables. The subclinical carotid atherosclerosis was defined as an increased mean IMT level of ≥75th percentile for the matched age, sex, and race and/or the presence of carotid plaque. Thirty-four (28.3%) of 120 had subclinical carotid atherosclerosis. The higher plasma levels of α-klotho had protective effect against subclinical carotid atherosclerosis (OR 0.006, p=0.034) in multivariate regression analysis. Plasma α-klotho levels had a significantly negative correlation with fasting glucose levels (r=-0.216, p=0.018) and mean IMT (r=-0.258, p=0.004) in multiple stepwise regression analyses. The optimal cutoff values of plasma α-klotho levels for the greatest sensitivity and specificity were calculated as 2.83 log10 [pg/ml] (sensitivity, 48.7%; specificity, 90.5%). These results show that plasma klotho levels were inversely associated with subclinical carotid atherosclerosis in HIV-infected patients receiving cART.

The two-edged sword: vasculitis associated with HIV and hepatitis C coinfection

Vasculitis has long been associated with chronic viral infections, thus the twin perils of the infection and the immune response against it that bedevils the specialties of infection and immunity. After HIV was identified, it too became associated with vasculitic syndromes. Later, hepatitis C virus was also isolated, identified and described with its own spectrum of vasculitic diseases, including hepatitis C virus-associated cryoglobulinaemia. With the increasing prevalence of HIV and hepatitis C virus coinfection, there has come an increasing recognition of the range of vasculitides that can occur in this population leading to significant morbidity, diagnostic and treatment challenges. In this review, we examine the epidemiology, pathogenesis and general principles of treatment of these systemic diseases in HIV/hepatitis C virus coinfected individuals.

Clinical factors associated with carotid plaque and intima-medial thickness in HIV-infected patients

PURPOSE

HIV-infected patients are at increased risk for cardiovascular disease, which may be mediated in part by inflammation. This study aimed to evaluate the risk factors of carotid plaque, and clinical factors associated with carotid atherosclerosis measured by carotid intima-medial thickness (cIMT) in HIV patients.

MATERIALS AND METHODS

Clinical and cardiometabolic factors as well as cIMT were prospectively measured in 145 HIV-infected participants who had received combined antiretroviral therapy for ≥6 months. The mean value of the bilateral average cIMT level was used as Mean-IMT in the analysis, and the greatest value among the measured cIMT levels was used as Max-IMT.

RESULTS

Among 145 patients, 34 (23.4%) had carotid plaque. Multivariate logistic regression analysis revealed three independent risk factors of carotid plaque: old age [odds ratio (OR) 6.16, 95% confidence interval (CI) 1.09-34.88; p=0.040], hypertension (OR 12.62, 95% CI 1.72-92.49; p=0.013) and higher low-density lipoprotein cholesterol (LDL-C) (OR 1.08, 95% CI 1.01-1.16; p=0.039). Levels of estimated glomerular filtration rate were inversely associated with Mean-IMT (r=-0.379, p<0.001) and Max-IMT (r=-0.389, p<0.001). Stepwise multivariate regression analyses revealed that age, total cholesterol and fasting glucose were positively correlated with cIMT, independent of other risk factors.

CONCLUSION

The presence of hypertension, old age and a higher level of LDL-C were independent risk factors of carotid plaque among HIV-infected subjects.

Central Nervous System Vasculopathy in HIV-Infected Children Enrolled in the Pediatric AIDS Clinical Trials Group 219/219C Study

BACKGROUND

Central nervous system (CNS) vasculopathy has been reported in human immunodeficiency virus-infected (HIV+) adults and children. In children, it often presents with HIV encephalopathy, stroke, or intracerebral aneurysms. The etiology, incidence, and risk factors of HIV-associated CNS vasculopathy in children are unknown.

METHODS

We identified HIV+ children with a diagnosis of vasculopathy or other cerebrovascular events among children enrolled between 1993 and 2004 in 2 prospective, multicenter cohort studies. Demographic and laboratory data, history of antiretroviral use, and signs, symptoms, and diagnostic studies pertaining to the CNS event were reviewed.

RESULTS

Among the 3338 HIV+ children, 51 had diagnoses that suggested CNS vasculopathy. Of these, 12 (24%) were included in this analysis, after excluding those with alternative diagnoses and those from closed sites. Among these 12, 4 (33%) were female, 4 (33%) were white, and 10 (83%) had perinatal HIV. Their average age at the event was 10.8 years with a median CD4 count of 22 cells/mm(3) and median HIV-1 viral load of 94 304 copies/mL. Fifty-eight percent of subjects had a history of opportunistic infections before the CNS event. Fifty percent had cerebral aneurysms on imaging. The overall incidence among HIV+ subjects was 3.4 cases per 10 000 person-years (95% confidence interval, 1.8-6.0).

CONCLUSIONS

CNS vasculopathy in HIV+ children is uncommon but more common than in the general pediatric population. Cerebral aneurysms are the most common manifestation. Although the pathogenesis remains unclear, older children and those with low CD4 counts and high HIV viral loads are at the highest risk.

Relationship between Younger Age, Autoimmunity, Cardiometabolic Risk, Oxidative Stress, HAART, and Ischemic Stroke in Africans with HIV/AIDS

Background and Purpose. It now appears clear that both HIV/AIDS and antiretroviral therapy (HAART) use are associated with higher risk of cardiovascular disease such as stroke. In this study, we evaluated the prevalence, the risk factors, and the cardiometabolic comorbidities of stroke in HIV/AIDS Central African patients. Methods. This hospital-based cross-sectional study collected clinical, laboratory, and imaging data of black Central African heterosexual, intravenous drug nonuser, and HIV/AIDS patients. Results. There were 54 men and 62 women, with a female to male ratio of 1.2 : 1. All were defined by hypercoagulability and oxidative stress. Hemorrhagic stroke was reported in 1 patient, ischemic stroke in 17 patients, and all stroke subtypes in 18 patients (15%). Younger age <45 years (P = .003), autoimmunity (P < .0001), and metabolic syndrome defined by IDF criteria (P < .0001) were associated with ischemic stroke. Conclusions. Clustering of several cardiometabolic factors, autoimmunity, oxidative stress, and lifestyle changes may explain accelerated atherosclerosis and high risk of stroke in these young black Africans with HIV/AIDS. Prevention and intervention programs are needed.

HIV infection and rheumatic diseases: the changing spectrum of clinical enigma

In this article, the authors discuss the occurrence and prevalence of rheumatic syndromes before and after highly active antiretroviral therapy became the usual mode of treatment. The immunologic, environmental, and genetic factors behind the combination of HIV infection and rheumatic manifestation contribute to the complexity of these diseases. Miscellaneous case reports are discussed in relation to HIV infection. The authors conclude that geriatric care of HIV patients is on the horizon as more people have access to newer, more effective therapy and mortality is on the decline. Younger HIV patients will be committed to a lifetime of therapy to address bone disease and other chronic problems. In the future, newer agents may steer the clinical scenario in unforeseen directions.

Primary vasculitis of the central nervous system in patients infected with HIV-1 in the HAART era

Angiitis of the central nervous system (CNS) in patients infected with HIV-1-is often associated with concomitant infection or lymphoproliferative disease of the CNS. Four HAART naïve patients infected with HIV-1 with severe stroke are described. Evidence of vasculitis was found by magnetic resonance angiography. Extensive investigations excluded concomitant opportunistic, lymphoproliferative or autoimmune disorders leading to the diagnosis of primary angiitis of the CNS. Despite initiation of HAART and prolonged suppression of viral replication, these patients remained severely immunosuppressed. The addition of corticosteroids led to a significant improvement of clinical symptoms. Primary angiitis of the CNS should be considered in patients with HIV and stroke. The prognosis of these patients remain poor despite HAART. These observations suggest that the vascular inflammatory process persists despite the control of viral load under HAART in patients with persistent immunosuppression.

Rheumatic conditions in human immunodeficiency virus infection

Many rheumatic diseases have been observed in HIV-infected persons. We, therefore, conducted a comprehensive literature search in order to review the prevalence, presentation and pathogenesis of rheumatic manifestations in HIV-infected subjects. Articular conditions (arthralgia, arthritis and SpAs) are either caused by the HIV infection itself, triggered by adaptive changes in the immune system, or secondary to microbial infections. Muscular symptoms may result from rhabdomyolysis, myositis or from side-effects of highly active anti-retroviral therapy (HAART). Osseous complications include osteonecrosis, osteoporosis and osteomyelitis. Some conditions such as the diffuse infiltrative lymphocytosis syndrome and sarcoidosis affect multiple organ systems. SLE may be observed but may be difficult to differentiate from HIV infection. Some anti-retroviral agents can precipitate hyperuricaemia and are associated with arthralgia. When indicated, immunosuppressants and even anti-TNF-alpha agents can be used in the carefully monitored HIV patient. Thus, rheumatic diseases and asymptomatic immune phenomena remain prevalent in HIV-infected persons even after the widespread implementation of highly active anti-retroviral therapy.

Diffuse Cerebral Vasculopathy in a HIV-Positive Patient with Recurrent Strokes

The causes of ischemic stroke in the young adult are diverse. Human immunodeficiency virus (HIV) infection-related vasculopathy is usually not included in the list of differential diagnoses. HIV-positive patients may present with acute neurologic dysfunction of different causes, among which cerebral infarction is an uncommon one. Herein, we report a HIV-infected young man who suffered from recurrent ischemic strokes with evidence of cerebral vasculopathy on serial magnetic resonance images.

Infection and musculoskeletal conditions: Rheumatologic complications of HIV infection

The pandemic caused by the human immunodeficiency virus (HIV) has entered its second quarter-century, with 40 million people now affected worldwide - particularly in Africa, where the impact has been most devastating. A complex array of rheumatic disease manifestations has been described, including diseases specific to HIV infection such as HIV-associated arthritis and the diffuse infiltrative lymphocytosis syndrome; other conditions which occur prominently in HIV-positive individuals include vasculitis, reactive and psoriatic arthritis and HIV-associated polymyositis, opportunistic musculoskeletal infections, and finally disorders that were originally ameliorated by HIV infection, such as rheumatoid arthritis and lupus. Effective antiretroviral treatment ameliorates many of these disorders; however, the introduction of highly active antiretroviral treatment (HAART) has introduced a new spectrum of disorders and new challenges confronting the clinician, including osteonecrosis, rhabdomyolysis, and, with immune reconstitution, the appearance de novo of a variety of autoimmune disorders and phenomena.

Cytomegalovirus Vasculitis and Mucormycosis Coinfection in Late-Stage HIV/AIDS

Case reports have previously been published describing various complications of cytomegalovirus (CMV) and mucormycosis in patients with HIV/AIDS. We describe the first case of CMV vasculitis and mucormycosis coinfection resulting in necrotizing myofascial cellulitis in an extremity in late stage HIV/AIDS. In AIDS patients, CMV reactivates when the CD4 count falls to less than 50 cells/microL (normal, 720-1440 cells/microL). Transient episodes of neutropenia in patients with HIV/AIDS who have low CD 4 cell counts are a predisposing factor for mucormycosis. These predisposing conditions were both present in our patient. Our case raises the question of CMV vasculitis leading to tissue ischemia as a possible contributing factor to the mucormycosis superinfection.

Complications musculaires de l’infection par le virus de l’immunodéficience humaine (VIH) à l’ère des trithérapies

Introduction of highly active antiretroviral therapy (HAART) has dramatically modified the natural history of HIV disease, but lengthening the survival of HIV-infected individuals has been associated with an increasing prevalence of iatrogenic conditions. Muscular complications of HIV infection are classified as follows: (1) HIV-associated myopathies and related conditions including polymyositis, inclusion-body myositis, nemaline myopathy, diffuse infiltrative lymphocytosis syndrome (DILS), HIV-wasting syndrome, vasculitis, myasthenic syndromes, and chronic fatigue; (2) iatrogenic conditions including mitochondrial myopathies, HIV-associated lipodystrophy syndrome, and immune restoration syndrome; (3) opportunistic infections and tumor infiltrations of skeletal muscle; and (4) rhabdomyolysis. These features are described in the present review.

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

Skeletal muscle involvement can occur at all stages of human immunodeficiency virus (HIV) infection, and may represent the first manifestation of the disease. Myopathies in HIV-infected patients are classified as follows: (1) HIV-associated myopathies and related conditions, including HIV polymyositis, inclusion-body myositis, nemaline myopathy, diffuse infiltrative lymphocytosis syndrome (DILS), HIV-wasting syndrome, vasculitic processes, myasthenic syndromes, and chronic fatigue; (2) muscle complications of antiretroviral therapy, including zidovudine and toxic mitochondrial myopathies related to other nucleoside-analogue reverse-transcriptase inhibitors (NRTIs), HIV-associated lipodystrophy syndrome, and immune restoration syndrome related to highly active antiretroviral therapy (HAART); (3) opportunistic infections and tumor infiltrations of skeletal muscle; and (4) rhabdomyolysis. Introduction of HAART has dramatically modified the natural history of HIV disease by controlling viral replication, but, in turn, lengthening of the survival of HIV-infected individuals has been associated with an increasing prevalence of iatrogenic conditions.

[Vasculitis associated with viral infections]

VIRUSES, THE CAUSE OF VASCULITIS: Although the majority of systemic vasculitis are of unknown causes, the responsibility of a viral infection has been formally demonstrated in some of them and specific treatment can permanently cure them. Each virus incriminated accounts for a particular type of vasculitis. HEPATITIS B VIRAL INFECTION (HBV): Is the cause of polyarteritis nodosa in 36 to 50% of cases. The onset of the symptomatology is acute, usually within a few months following the infection; it is comparable to that observed in the absence of HBV infection. CRYOGLOBULINEMIA RELATED TO THE HEPATITIS C VIRUS (HCV): The clinical manifestations are those of systemic vasculitis with particular tropism for the skin (involvement generally inaugural and almost constant), peripheral nerves and the glomerula. They occur fairly late during the infection. VASCULITIS ASSOCIATED WITH HIV INFECTION: There is strong tropism for the peripheral (multi-neuritis) and central nervous system. During acute parvovirus B19 infection Vasculitis lesions have occasionally been reported following the viremic phase, generally limited to one or several flares of vascular purpura predominating on the lower limbs. FOLLOWING VARICELLA-HERPES ZOSTER INFECTION: Vasculitis occasionally develops in the form of a central neurological deficiency (locomotor deficiency with or without aphasia around one month after an ophthalmologic herpes zoster) or involving the retina or, more rarely, the skin or the kidneys. VASCULITIS ASSOCIATED WITH CYTOMEGALOVIRAL INFECTION: Predominantly observed in immunodepressed patients, vasculitis after CMV infection is diffuse and basically involving the digestive tube, notably the colon, the central nervous system and the skin. A RARE COMPLICATION OF AN HTLV1 INFECTION: Vasculitis of the retina often in the form of necrotic retinitis is often associated with spasmodic paraparessia.

THERAPEUTIC STRATEGY

For many vasculitis of viral origin, corticosteroid and immunosuppressive treatments are only indicated in second intention following failure with antiviral agents and the combination of antivirals and plasma exchanges.

Stroke in black South African HIV-positive patients: a prospective analysis

BACKGROUND AND PURPOSE

Stroke associated with HIV infection is poorly characterized. In this study we analyze the association in a black African population.

METHODS

The clinical, laboratory, and radiological characteristics of 35 hospital-based black South African, heterosexual, HIV-infected patients who did not abuse intravenous drugs and presented with strokes were prospectively studied. The patients were antiretroviral therapy naive. Patients with other intracranial space-occupying lesions were excluded from the study.

RESULTS

The age range was 20 to 61 years (mean, 32.1 years). There were 21 female and 14 male patients, with a female to male ratio of 1.5:1. Cerebral infarction occurred in 33 patients (94%) and intracerebral hemorrhage in 2 patients (6%). Underlying causes were identified in 30 of the 35 patients (86%) and included coagulopathies, meningitis, cardioembolism, and hypertension. The most common coagulopathy was protein S deficiency. No cause was found in 5 patients (14%).

CONCLUSIONS

The results are similar to data from studies on young black African stroke patients who are HIV negative.

HIV and autoimmunity

The association of immune dysfunction in patients with human immunodeficiency virus (HIV) infection and AIDS and the development of autoimmune diseases is intriguing. Yet, the spectrum of reported autoimmune phenomena in these patients is increasing. An infectious trigger for immune activation is one of the postulated mechanisms and derives from molecular mimicry. During frank loss of immunocompetence, autoimmune diseases that are predominantly T cell subtype CD8 driven predominate. There is evidence for B cell stimulation and many autoantibodies are reported in HIV patients. We propose a staging of autoimmune manifestations related to HIV/AIDS manifestations and the total CD4 count and viral load that may be beneficial in identifying the type of autoimmune disease and establishing the proper therapy. In stage I there is the acute HIV infection, and the immune system is intact. In this stage, autoimmune diseases may develop. Stage II describes the quiescent period without overt manifestations of AIDS. However, there is a declining CD4 count indicative of some immunosuppression. Autoimmune diseases are not found. During stage III there is immunosuppression with a low CD4 count and the development of AIDS. CD8 T cells predominant and diseases such as psoriasis and diffuse immune lymphocytic syndrome (similar to Sjogren's syndrome) may present or even be the initial manifestation of AIDS. Also during this stage no autoimmune diseases are found. In stage IV there is restoration of immune competence following highly active anti-retroviral therapy (HAART). In this setting, there is a resurgence of autoimmune diseases. The frequency of reported rheumatological syndromes in HIV-infected patients ranges from 1 to 60%. The list of reported autoimmune diseases in HIV/AIDS include systemic lupus erythematosus, anti-phospholipid syndrome, vasculitis, primary biliary cirrhosis, polymyosits, Graves' disease, and idiopathic thrombocytopenic purpura. Also, there is an array of autoantibodies reported in HIV/AIDS patients which include anti-cardiolipin, anti-beta2 GPI, anti-DNA, anti-small nuclear ribonucleoproteins (snRNP), anti-thyroglobulin, anti-thyroid peroxidase, anti-myosin, and anti-erythropoietin antibodies. The association of autoantibodies in HIV-infected patients to clinical autoimmune disease is yet to be established. With the upsurge of HAART, the incidence of autoimmune diseases in HIV-infected patients is increasing. In this review, we describe the various autoimmune diseases that develop in HIV/AIDS patients through possible mechanisms related to immune activation.

Neuromuscular complications of connective tissue diseases

The connective tissue diseases, such as rheumatoid arthritis, Sjögren's syndrome, systemic lupus erythematosus, systemic sclerosis, and vasculitis, may cause various disorders of the peripheral nervous system. In this review, the clinical effects of the connective tissues diseases on nerve and muscle are examined with particular attention to mononeuritis multiplex, distal symmetric neuropathy, fulminant motor neuropathy, compression neuropathy, sensory neuronopathy, and trigeminal sensory neuropathy.

The changing spectrum of rheumatic disease in human immunodeficiency virus infection

CONTEXT

Although it has been known for over 15 years that a number of rheumatic diseases occur in patients with human immunodeficiency virus (HIV) infection, increasing knowledge about these disorders and advances in HIV treatment need to be considered in approaching patients with HIV-associated rheumatic disease.

OBJECTIVE

To examine the clinical, pathologic, and therapeutic features of HIV-associated rheumatic diseases in the context of what is known about the immunology of HIV infection.

DATA SOURCES

The author's own extensive collection of references, supplemented by PubMed Medline searches for articles in English-language journals published between 1985 and 2000. The indexing term HIV and the following coindexing terms were used for searching: arthritis, Reiter's syndrome, psoriatic arthritis, rheumatoid arthritis, osteonecrosis, vasculitis, pulmonary hypertension, myositis, myopathy, fibromyalgia, septic arthritis, parotid enlargement, diffuse infiltrative lymphocytosis syndrome, systemic lupus erythematosus, septic arthritis, mycobacterial arthritis, fungal arthritis, autoantibodies, anti-cardiolipin antibodies, and anti-neutrophilic cytoplasmic antibodies.

STUDY SELECTION

All papers identified in the literature search were reviewed. Studies presenting data that merely confirmed previous studies were not included in the analysis.

DATA EXTRACTION

All identified papers were abstracted by the author. Letters to the editor were included only if a new observation had been made.

DATA SYNTHESIS

This was a qualitative review of papers published, with new knowledge about these disorders summarized and presented.

RESULTS

Despite new treatments for HIV, reports of rheumatic diseases presenting in AIDS patients persist, especially in HIV-associated arthritis, diffuse infiltrative lymphocytosis syndrome, HIV-associated vasculitis, and polymyositis. However, new HIV treatments may ameliorate these diseases.

CONCLUSIONS

The spectrum of HIV-associated rheumatic disease remains a diagnostic and therapeutic challenge for the clinician. The impact of changes in HIV treatment on these disorders requires further assessment.

Rheumatic manifestations of HIV-AIDS

Infection by human immunodeficiency virus is characterized by a myriad of clinical manifestations affecting almost every organ system in the body. If untreated, it follows an inexorable course, leading to a profound state of immunosuppression and eventually death from opportunistic infection and/or development of lymphoproliferative malignancy and Kaposi's sarcoma. Rheumatic manifestations may develop at any time of the clinical spectrum, but usually are more often seen in late stages. A variety of disorders may be seen, particularly Reiter's syndrome and undifferentiated spondyloarthropathy. Most patients do well with conventional anti-inflammatory therapy, but some will require the use of immunosuppressive-cytotoxic therapy.

Use of noninvasive electroacupuncture for the treatment of HIV-related peripheral neuropathy: a pilot study

OBJECTIVES

The main objective of this study was to test the hypothesis that low-voltage non-invasive electroacupuncture will improve the condition of neuropathic human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) patients.

DESIGN

A prospective study using HIV/AIDS patients who had antiretroviral drug-induced neuropathy. Eleven patients were enrolled, but complete data was obtained from only 7. Non-invasive skin electrodes were placed on leg acupuncture points BL60, ST36, K1, LIV3, and low-voltage current passed for 20 minutes every day for 30 days. Patients were assessed preintervention and postintervention with MOS-HIV 30-item instrument questionnaire and tibial H-reflex was similarly recorded from the right calf muscle.

RESULTS

There was improvement in the condition of all 7 patients. They felt much better and reported feelings of increased physical strength. Outcomes on MOS-HIV 30-item instrument showed significant overall improvement in functional activities (pre 33+/-10, post 38.4+/-9.6, p = 0.02 MANOVA). This was confirmed by postintervention H-reflex parameters; H-max and direct muscle response (M-response) amplitudes were potentiated in relation to pretreatment values (H-max: pre = 1.19+/-1.2, post = 2.68+/-1.9, p<0.05; M-response: pre = 0.93+/-1.1, post = 2.34+/-1.8, p<0.05); M-response latency decreased in relation to pretreatment value (pre = 9.7+/-1.8, post = 7.8+/-1.9, p<0.01).

CONCLUSION

The results support the hypothesis that low-voltage electroacupuncture will improve the condition of the neuropathic HIV/AIDS patient.