Q4: Clinical Case Conference on Human Immunodeficiency Virus

1. Q4: Clinical Case Conference onHuman Immunodeficiency Virus Chua, Kathleen S.

2. Clinical Case Conference on Human Immunodeficiency Virus 4. Enumerate rheumatic conditions found in HIV-infected individuals

3. U. A. Walker, A. Tyndall and T. Daikeler Rheumatic conditions in human immuno- deficiency virus infection Rheumatology 2008;47:952–959

4. Rheumatic conditions found in HIV-infected individuals • HIV-associated arthritis • Nonerosive-oligoarthritis of the legs of unknown etiology • Found in up to 1% of patients • Usually self-limited and lasts less than 6 weeks • Reiter's syndrome (reactive arthritis) • common in persons with HIV infection who are HLA-B27 positive • best treatment is HIV suppression and tumor necrosis factor (TNF)-alpha antagonists. • Septic arthritis • major joints affected are the sternoclavicular and leg joints. U. A. Walker, A. Tyndall and T. Daikeler Rheumatic conditions in human immuno- deficiency virus infection Rheumatology 2008;47:952–959

5. Rheumatic conditions found in HIV-infected individuals • Indinavir-associated hyperuricemia and arthralgia: • Indinavir has been implicated in HIV, but crystals were not detected. • Gout: • Hyperuricemia is common with HIV • Ritonavir boosting has been implicated • Rhabdomyolysis: • May complicate primary HIV infection or complicate statin use in patients receiving highly active antiretroviral therapy (HAART) U. A. Walker, A. Tyndall and T. Daikeler Rheumatic conditions in human immuno- deficiency virus infection Rheumatology 2008;47:952–959

6. U. A. Walker, A. Tyndall and T. Daikeler Rheumatic conditions in human immuno- deficiency virus infection Rheumatology 2008;47:952–959 • HIV-associated polymyositis: • Polymyositis has been reported in as many as 2% to 7% of persons with HIV infection • Muscle biopsy shows CD8 cell infiltrates and viral antigen. • HIV-associated polymyositis has been reported to be clinically and histologically identical to idiopathic polymyositis, but has a good prognosis and responds well to immunosuppressive treatment. • Zidovudinemyopathy: • seen exclusively with zidovudine • characterized by muscle weakness and normal or slightly elevated creatinekinase levels • Electron microscopy shows abnormal mitochondria that resolves with drug discontinuation. • Vasculitis: • This is described in early HIV disease in patients with high CD4 counts, as well as later in patients with severe immunosuppression. • Biopsies show nonspecific neutrophilic or monocytic vascular inflammation and often other clinical features, such as rash or peripheral neuropathy or both. • Some patients have cryoglobulinemia • Some have HIV-associated polyarteritisnodosa • Some have large-vessel complications, including aneurysms or strokes.

7. Diffuse infiltrative lymphocytosis syndrome: • Prevalence in the HIV population is approximately 3%. • Present with bilateral painless parotid gland enlargement, lacrimal gland enlargement, and sicca symptoms • The pathogenesis is thought to be an excessive response to HIV with CD8 lymphocytosis, and it may be associated with lymphoid interstitial pneumonia in up to 31%, or involvement of muscles or liver. • HAART appears to be effective given that the incidence is decreasing • Systemic lupus erythematosus: • This condition usually improves in patients with untreated HIV infection, which fits the current concepts of the importance of CD4 cells in pathogenesis. • However, this can also be a component of immune reconstitution inflammatory syndrome. • Systemic lupus erythematosus may also be the source of a false-positive screening test for HIV, but not the confirmatory Western blot. • Sarcoidosis: • When sarcoidosis coexists with HIV, most patients who are symptomatic have CD4 counts exceeding 200 cells/µL, which is consistent with the current concept of the role of CD4 cell lymphocytes in the pathogenesis of granuloma formation. • At present, most patients with active sarcoidosis have this as a result of immune reconstitution inflammatory syndrome. U. A. Walker, A. Tyndall and T. Daikeler Rheumatic conditions in human immuno- deficiency virus infection Rheumatology 2008;47:952–959