HIV infection-associated inflammatory musculoskeletal disorders

Pathogens in Vasculitis: Is It Really Idiopathic?

Vasculitis is an autoimmune disease characterized by the infiltration of leukocytes in blood vessels. An increasing number of studies on human and animal models have implicated various microorganisms in the pathogenesis of vasculitis. Previous studies have shown the presence of infectious agents, including viruses, bacteria, and fungi, in diseased vessels. However, despite continued research, the link between infection and vasculitis is not fully understood, possibly owing to the lack of appropriate animal models that mirror human disease and the technical limitations of pathogen detection in blood vessels. Among the pathogen-induced animal models, Candida albicans water-soluble fraction (CAWS)-induced coronary arteritis is currently considered one of the representative models of Kawasaki (KD) disease. Advances in metagenomic next-generation sequencing have enabled the detection of all nucleic acids in tissue, which can help identify candidate pathogens, including previously unidentified viruses. In this review, we discuss the findings from reports on pathogen-associated vasculitis in animal models and humans, with a specific focus on the investigation of the pathogenesis of vasculitis. Further studies on animal models and microbes in diseased vessels may provide important insights into the pathogenesis of vasculitis, which is often considered an idiopathic disease.

Risk Factors Associated With Progression to Surgical Release After Injection of Trigger Digits

Introduction:

The mainstay of trigger finger treatment is a corticosteroid injection of the affected digits and is associated with a very high success rate. However, some patients do not respond to nonsurgical management and undergo subsequent surgical release. The purpose of this study is to investigate the comorbidities that predispose patients to progressing from injection to surgical release.

Methods:

Patient data were obtained from a national insurance database. All patients aged 20 years or older who underwent trigger digit injection were included. Any injection that did not specify the digit was excluded. Subsequent procedures, including repeat injection and surgical release, were identified using relevant Current Procedural Terminology codes. A multivariate model was constructed to evaluate potential risk factors for requiring release after prior injection of the same digit. Stepwise backward selection was used to retain significant variables.

Results:

A total of 42,537 trigger digits were identified in 31,830 patients, most of whom were female. The right hand was affected more commonly than the left. The middle and ring fingers were the most commonly affected digits. Over 80% of all trigger digits underwent only a single injection, and approximately 90% of injected digits did not require subsequent release. In the multivariate model, factors associated with higher risk of release were male sex, involvement of additional digits, multiple injections of the same digit, chronic pulmonary disease, HIV/AIDS, obesity, alcohol abuse, and depression. The model also found small fingers to be less likely to progress to release.

Discussion:

Patients with the risk factors identified in this study are more likely to progress to surgical release after trigger finger injection. Although prospective studies are required, the information may be beneficial in counseling patients and their treatment options.

Child functioning and disability in children living with human immunodeficiency virus in a semi-rural healthcare setting in South Africa

Background

Children living with HIV (CLHIV) often experience HIV-related impairment and disability.

Aim

The study sought to understand the level of child functioning and access to rehabilitative care in the context of South African healthcare in order to inform an integrated rehabilitative framework.

Setting

District level semi-rural healthcare facility in KwaZulu-Natal.

Methods

The Washington Group/United Nations International Children’s Emergency Fund Module on Child Functioning, was administered to carers of CLHIV aged between 5 and 10 years, and accessing care at the study setting.

Results

Forty-four caregivers of children receiving treatment from June 2018 to March 2019, at the facility, participated. Four (9.1%) children had difficulty with seeing, 13 (29.5%) children had difficulty with hearing and 10 (22.7%) children had difficulty with walking. In the cognitive and behavioural domains, 17 (38.6%) children reported difficulties in communication and concentration, with 16 (36.4%) children experiencing difficulties in learning and remembering. Difficulties reported in accepting change and controlling behaviour were both experienced by 23 (52.3%) children. Although many children experiencing impairments were referred for rehabilitation, many caregivers did not follow-up after the initial assessment, because of financial constraints, lack of time and transport restrictions.

Conclusion

Functional difficulties were frequently experienced by children living with HIV. Disability screening would be beneficial at various points of care to promote early identification and timely referral to healthcare professionals. Decentralising rehabilitative care to homes and communities could offer a solution to some of the reported barriers to accessing care.

Autoimmune blistering disorders in the setting of human immunodeficiency virus infection

The interplay between immune dysfunction and human immunodeficiency virus (HIV) is complex. Reports of autoimmune disorders including autoimmune bullous disorders (AIBDs) have been increasing in prevalence in the HIV population since the introduction of highly active antiretroviral therapy in 1995. We offer a literature review of clinical experiences in various AIBDs with particular emphasis on therapeutic management as well as a brief overview of the mechanisms that explain the relationship between AIBD and HIV. Because immunosuppressants are first-line therapies for AIBD treatment, careful consideration is warranted when considering management in the HIV population.

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.

Prevalence and Predictors of Thyroid Dysfunction in Patients with HIV Infection and Acquired Immunodeficiency Syndrome: An Indian Perspective

Background. Predictors of thyroid dysfunction in HIV are not well determined. This study aimed to determine the prevalence and predictors of thyroid dysfunction in HIV infected Indians. Methods. Consecutive HIV patients, 18-70 years of age, without any severe comorbid state, having at least 1-year follow-up at the antiretroviral therapy clinic, underwent clinical assessment and hormone assays. Results. From initially screened 527 patients, 359 patients (61.44 ± 39.42 months' disease duration), having good immune function [CD4 count >200 cell/mm(3): 90.25%; highly active antiretroviral therapy (HAART): 88.58%], were analyzed. Subclinical hypothyroidism (ScH) was the commonest thyroid dysfunction (14.76%) followed by sick euthyroid syndrome (SES) (5.29%) and isolated low TSH (3.1%). Anti-TPO antibody (TPOAb) was positive in 3.90%. Baseline CD4 count had inverse correlation with TPOAb after adjusting for age and body mass index. Stepwise linear regression revealed baseline CD4 count, TPOAb, and tuberculosis to be best predictors of ScH after adjusting for age, weight, duration of HIV, and history of opportunistic fungal and viral infections. Conclusion. Burden of thyroid dysfunction in chronic HIV infection with stable immune function is lower compared to pre-HAART era. Thyroid dysfunction is primarily of nonautoimmune origin, predominantly ScH. Severe immunodeficiency at disease onset, TPOAb positivity, and tuberculosis were best predictors of ScH.

Association between antiretrovirals and thyroid diseases: a cross-sectional study

OBJECTIVE

This study aims to estimate the prevalence of thyroid diseases and anti-TPO status. We searched for an association among presence of immune reconstitution and use of stavudine, didanosine and protease inhibitors with thyroid diseases.

MATERIALS AND METHODS

A cross-sectional study was performed to analyze the records of 117 HIV-infected patients who had their CD4+ cell count, viral load, anti-TPO, TSH and free T4 levels collected on the same day. Immune reconstitution was considered in those whose T CD4+ count was below 200 cells/mm3, but these values increased above 200 cells/mm3 after the use of antiretrovirals. The odds ratio obtained by a 2x2 contingency table and a chi-square test were used to measure the association between categorical variables.

RESULTS

The prevalence of thyroid disease was 34.18%; of these, 4.34% were positive for anti-TPO. There was an association of risk between stavudine use and subclinical hypothyroidism (OR = 4.19, 95% CI: 1.29 to 13.59, X2 = 6.37, p = 0.01). Immune reconstitution achieved protection associated with thyroid disease that was near statistical significance OR = 0.45, 95% CI: 0.19 to 1.04, X2 = 3.55, p = 0.059.

CONCLUSION

The prevalence of thyroid disease in the sample studied was higher than what had been found in the literature, with a low positive anti-TPO frequency. The historical use of stavudine has an association of risk for the presence of subclinical hypothyroidism, and immune reconstitution has trends towards protection for the presence of thyroid diseases.

Update on imaging of non-infectious musculoskeletal complications of HIV infection

Acquired immunodeficiency syndrome (AIDS) results from infection with human immunodeficiency virus (HIV), producing an immunodeficient state and severe pathology across multiple organ systems. Musculoskeletal involvement is particularly prevalent in this population with both infectious and non-infectious complications encountered, but it is suggested that the latter will affect 72% of HIV-infected individuals. In this review we aim to provide an update on the imaging characteristics of the non-infectious manifestations. The conditions include HIV-related arthritis as well as various malignancies, myositis, anaemia, osteonecrosis, rhabdomyolysis, hypertrophic osteoarthropathy and therapy-related side effects. For the clinician, the diagnostic challenge lies in differentiating disease-related symptoms from therapy-related side effects, particularly when clinical and laboratory features can be non-specific. This is especially difficult following the widespread introduction of highly active anti-retroviral therapy (HAART). Imaging investigations and MRI in particular have proven vital for facilitating early diagnosis and enabling prompt treatment. Furthermore, wider availability of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) has allowed whole-body assessment for staging and treatment response of malignancy. Understanding the pathogenesis of the various conditions and recognising their imaging features is essential for the clinical radiologist.

Interactions between prostaglandins, leukotrienes and HIV-1: possible implications for the central nervous system

In HIV-1-infected individuals, there is often discordance between viremia in peripheral blood and viral load found in the central nervous system (CNS). Although the viral burden is often lower in the CNS compartment than in the plasma, neuroinflammation is present in most infected individuals, albeit attenuated by the current combined antiretroviral therapy. The HIV-1-associated neurological complications are thought to result not only from direct viral replication, but also from the subsequent neuroinflammatory processes. The eicosanoids - prostanoids and leukotrienes - are known as potent inflammatory lipid mediators. They are often present in neuroinflammatory diseases, notably HIV-1 infection. Their exact modulatory role in HIV-1 infection is, however, still poorly understood, especially in the CNS compartment. Nonetheless, a handful of studies have provided evidence as to how these lipid mediators can modulate HIV-1 infection. This review summarizes findings indicating how eicosanoids may influence the progression of neuroAIDS.

Rat bite fever as a presenting illness in a patient with AIDS

The etiology of culture-negative septic arthritis is poorly characterised in persons infected with human immunodeficiency virus (HIV). New molecular methods may assist in the investigation of culture-negative infections of sterile sites, including septic arthritis. We describe the first case of septic arthritis due to the cause of rat bite fever (RBF), Streptobacillus moniliformis, confirmed by 16S rRNA sequence analysis, in a patient with newly diagnosed HIV infection.

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.

HIV infection and shoulder pain: a challenging case

With better understanding of the pathogenesis of AIDS and the advent of anti-retroviral medications, patients with HIV are living longer and the probability that they will suffer musculoskeletal complications are increasing. There is a vast array of musculoskeletal impairments including rheumatologic, infectious, and non-infectious conditions. We report a 53-year-old man with longstanding shoulder pain, weakness, and spasticity of the upper extremity which was diagnosed as adhesive capsulitis secondary to brain abscess. Musculoskeletal problems may be complicated with neurological involvement as in our case and patients should be investigated for possible underlying life-threatening disease.

Emergence of manifestations of HIV infection in a case of systemic lupus erythematosus following treatment with IV cyclophosphamide

Systemic lupus erythematosus (SLE) and infection with human immunodeficiency virus are rarely seen in the same patient. We describe a case of a 32-year-old lady, who was diagnosed with systemic lupus erythematosus (anti-dsDNA antibody positive) and was initially serologically negative for human immunodeficiency virus (HIV) infection. Following three cycles of IV cyclophosphamide, she was subsequently found to be infected with HIV, with marked depletion of peripheral CD4-positive T lymphocytes. While her SLE remained completely inactive, the course of HIV was rapidly progressive, suggesting that retroviral replication may have been enhanced by the underlying immunomodulation caused by cyclophosphamide and also by SLE per se.

Imaging Findings in Musculoskeletal Complications of AIDS

Patients with human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) are susceptible to a variety of complications that can affect the musculoskeletal system. These complications can be infectious, inflammatory, or neoplastic or can take some other form. Infection (cellulitis, necrotizing fasciitis, soft-tissue abscess, pyomyositis, osteomyelitis, septic arthritis) is the most common complication. Inflammatory processes include various arthritides as well as polymyositis. Non-Hodgkin lymphoma and Kaposi sarcoma are the two most common neoplasms in this patient population. Miscellaneous disorders include osteonecrosis, osteoporosis, rhabdomyolysis, anemia-related abnormal bone marrow, and hypertrophic osteoarthropathy. The underlying mechanisms leading to these diseases are complex and not fully understood but are thought to be multifactorial. Radiology may play an important role in early diagnosis and treatment planning in this population, in whom clinical and laboratory findings are commonly equivocal and nonspecific. Although biopsy is often necessary for the final diagnosis, it is important for the radiologist to be familiar with the different types of musculoskeletal disease in HIV-positive and AIDS patients so that an appropriate differential diagnosis can be established.

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.

Musculoskeletal manifestations of human immunodeficiency virus infection

Musculoskeletal manifestations of the human immunodeficiency virus (HIV) are common and are sometimes the initial presentation of the disease. Knowledge of the conditions affecting muscle, bone, and joints in HIV-infected patients is essential for successful management. Myopathies may be caused by pyogenic infection (eg, pyomyositis), idiopathic inflammation (eg, polymyositis), or drug effect (eg, AZT myopathy). Characteristic skeletal infections, such as tuberculosis and bacillary angiomatosis, require a high index of suspicion for accurate diagnosis. Neoplastic processes, such as non-Hodgkin's lymphoma and Kaposi's sarcoma, occur more frequently as the immune system deteriorates. Inflammatory and reactive arthropathies are more prevalent in HIV-positive than HIV-negative individuals and include Reiter's syndrome, psoriatic arthritis, HIV-associated arthritis, painful articular syndrome, acute symmetric polyarthritis, and hypertrophic osteoarthropathy. Patients with atypical musculoskeletal complaints and a suspected history of exposure should be tested for HIV.

Imaging of musculoskeletal and spinal infections in AIDS

The diagnosis of common and opportunistic infections in patients with HIV begins with clinical suspicion and involves relatively standard methodology. Musculoskeletal infection is sometimes the first manifestation of an HIV infection. In patients with HIV, the infections tend to be more advanced at presentation, occur in unusual sites, are caused by a wider spectrum of pathogens, and tend to show an inadequate or delayed response to therapy. The index of suspicion for musculoskeletal infections should be high when reviewing imaging studies of patients with HIV.

Worsening of Arthritis with Antiretroviral Therapy: The Coexistence of Rheumatoid Arthritis and Human Immunodeficiency Virus Infection Revisited

The observation of remission occurring in several rheumatoid arthritis (RA) patients who subsequently became infected with human immunodeficiency virus (HIV) suggested that these diseases are mutually exclusive. Subsequent case reports of progression of destructive rheumatoid arthritis, even with depleted CD4 cell counts, seemed to imply that active RA may be independent of CD4 lymphocyte number and function. We report an HIV-infected individual who developed rheumatoid arthritis, which rapidly worsened with the initiation of antiretroviral therapy. The worsening disease course correlated with the increase in CD4 cell count and with the decrease in HIV viral load, perhaps suggesting a central role for the CD4 cells in the pathogenesis of rheumatoid arthritis in this particular patient. Among the therapeutic options to consider in such a patient, indomethacin and hydroxychloroquine may offer additional benefit of inhibiting viral replication. The cautious use of methotrexate with several limitations is possible, although sulfasalazine (to which our patient responded) may be a safer option.

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.