Management of Inflammatory Arthritis in Patients With Comorbid HIV Infection

Challenges of managing inflammatory arthritis in patients infected with HIV include difficulties in assessing disease activity and limited safety information for the use of immunosuppresive drugs in this patient population.

A review of the literature highlights the challenges associated with the diagnosis and treatment of patients with concomitant inflammatory arthritis and human immunodeficiency virus (HIV) infection.1 

HIV infection is characterized by progressive depletion of CD4+ T-lymphocytes, placing the patient at risk for opportunistic infections. Reactive arthritis, psoriatic arthritis (PsA), rheumatoid arthritis (RA), and painful articular syndrome have been described in association with HIV infection. In addition, nearly 50% of patients with HIV infection develop a mononucleosis-like illness characterized by myalgias, arthralgias, lymphadenopathy, fever, and malaise. 

“Patients infected with HIV have been shown to have a higher risk of developing rheumatic diseases… HIV-positive patients [with] musculoskeletal involvement have reduced quality of life when compared to those without rheumatic symptoms,” according to Tochukwa Adizie, MD, of the Heart of England National Health Service Trust teaching hospital in Birmingham, UK, in an email interview with Rheumatology Advisor. 

Dr Adizie and colleagues conducted a computer-assisted literature search to review the association between HIV and rheumatologic disorders.

HIV-associated arthropathy is commonly characterized as an oligoarthritis with asymmetric involvement of the knees and ankles in male patients. However, patients with HIV may also have monoarthritis or polyarthritis with similarities to RA in deformity and radiographic evidence. Typically, the arthritis peaks after 1 to 6 weeks, but some patients with HIV develop long-term disability related to destructive arthropathy.  

Diagnostic evaluation may reveal negative human leukocyte antigen (HLA)-B27, antinuclear antigen (ANA), and rheumatoid factor.  Normal glucose levels are usually found on synovial fluid aspirate analysis.  Detection of HIV DNA, tubuloreticular inclusions, and p24 antigen in synovial fluid analyses combined with epidemiology evidence of a high prevalence of rheumatic diseases in HIV patients point to HIV having a direct inflammatory effect on the synovium.  

Painful articular syndrome has been described in more advanced disease in as many as 10% of patients with HIV in Africa. It is characterized by asymmetric, lower extremity joint and bone pain without synovitis lasting less than 24 hours. The pain may become debilitating and appear out of proportion to the clinical exam.   

Spondyloarthritis (SpA) was noted to be uncommon in sub-Saharan Africa prior to the HIV epidemic, in part because of a low prevalence of the HLA-B27 allele in the population. Reactive arthritis linked to HIV typically presents as a peripheral oligoarthritis of the lower extremities associated with enthesitis and mucocutaneous involvement, such as urethritis and keratoderma blenorrhagicum. Uveitis and axial skeletal involvement may occur but are not common.