Introduction

The spectrum of rheumatic diseases in HIV-infected patients continues to develop. HIV infection itself may cause rheumatic symptoms such as arthralgias and myalgias, as well as positive serologies that may confound diagnosis. A basic understanding of how the prevalence of certain rheumatic diseases may change as a patient’s HIV status evolves, as well as knowledge of more rare disease syndromes in HIV that may mimic or overlap with traditional rheumatic diseases, can aid in more accurate diagnosis and treatment.

General Principles

• Polyclonal B cell activation from chronic inflammation in HIV induces multiple autoantibodies
  
  
  
  • 45% of HIV patients have polyclonal gammopathy
    
  • 20% of HIV patients have low-titer RF and ANA positivity
    
  • Up to 90% of patients with AIDS have IgG anticardiolipin antibody
    
  • These autoantibodies are rarely clinically significant, and do not correlate with developing a particular rheumatic syndrome
  
  
• HIV+ patients will often have atypical patterns of serologies (i.e. low-titer ANA+, centromere, RNP, SSB+, all in the same patient)
  
• Many of these patients may be initially misdiagnosed as having rheumatic disease instead of HIV

The Spectrum of Rheumatic Disease in HIV

• SLE and rheumatoid arthritis are CD4+ T cell-mediated rheumatic diseases
  
  
  
  • Therefore as CD4 count goes down with progressive HIV infection, these diseases become quiet
    
  • It is rare for either disease to develop in HIV-infected individuals, especially if CD4 count is <200 cells/μL
    
  • Conversely, with HIV treatment and immune reconstitution, SLE and RA may develop or recur, and may be quite severe
  
  
• Psoriasis and psoriatic arthritis are CD8+ T cell-mediated rheumatic diseases
  
  
  
  • During the course of progressive HIV infection, CD8-driven processes tend to worsen, as the CD4/CD8 ratio evolves
    
  • Therefore psoriasis and psoriatic arthritis become more prevalent in HIV patients as their CD4 count drops, and can be quite severe
    
  • Often highly active antiretroviral therapy (HAART) and immune reconstitution alone are effective for either condition
    
  • Refractory skin and joint involvement may require methotrexate (MTX), sulfasalazine (SSZ), or a TNF inhibitor
    
  • Hydroxychloroquine is typically avoided as it can worsen psoriasis; additionally new data suggests it is associated with a decline in CD4 cell count and increased viral replication when used in HIV-infected patients not taking antiretroviral therapy

Approach to Evaluating Joint Pain in HIV

• HIV-associated arthralgias
  
  
  
  • Up to 45% of HIV-infected patients may have unexplained arthralgias
    
  • Many report arthralgias/myalgias as part of an HIV seroconversion syndrome
    
  • Some hypothesize a role of elevated circulating cytokines or transient bone ischemia in response to HIV infection
    
  • Patients with isolated arthralgia rarely progress to inflammatory joint disease
    
  • Primary treatments include non-narcotic analgesics and reassurance
    
  • Autoantibodies are sometimes difficult to interpret in this setting
  
  
• HIV-associated arthritis
  
  
  
  • Similar to a “seronegative rheumatoid arthritis”
    
  • Inflammation/synovitis is visible on exam
    
  • Usually an asymmetric oligoarthritis, primarily involving lower extremities
    
  • Self-limited, usually lasts <6 weeks
    
  • Some case reports of more chronic, erosive arthritis but this is rare
    
  • Treatment: NSAIDs, low-dose glucocorticoids in severe cases for a limited amount of time; plaquenil or SSZ also have been used