The Musculoskeletal system HIV and other infections

Johan van Rensburg

HIV AND THE MUSCULOSKELETAL SYSTEM

Important concepts in HIV and the musculoskeletal system

Concerning the HIV infection HIV modifies the presentation, clinical picture and outcome of auto-immune

diseases HIV infection may mimic many auto-immune diseases Auto-antibodies may be present in both HIV (low titers) and auto-immune

diseases Considering immune suppression

HIV-virus more responsible for manifestations in early disease Opportunistic infections and malignancies more prominent in late disease

Concerning the drugs The drugs used to modify auto-immune disease may modify the outcome of

HIV infection HAART may present with musculoskeletal adverse events Drug interactions must always be considered

Associated conditions Same principles of diagnosis and management apply as in patient without HIV

(after consideration of the above)

Musculoskeletal manifestations in HIV

More prevalent in late stagesWide spectrum of diseasePrevalence uncertain

Quality of life influenced by pain, loss of function and systemic complications

Risk factors for HIVSexual historyIDUHemophiliacs

Examples of HIV and MS System

Keep the normal course of HIV infection in mind

Remember Components of the MS-system

Soft tissue Muscles

• Miopathy (virus and drugs), miositis (inflammatory or infective) Ligaments and enthesis

• involved in reactive athritis and other sero-negative spondyloarthropathies Blood vessels

• Vasculitis, drug reactions and coagulopathies Fat and other connective tissue

• Involved in infection, drug reactions and crystal induced inflammation Joints

Synovial joints • Infective: virus, septic arthritis, TB• Reactive • Auto-immune

Fibrous joints• Reactive athritis and other sero-negative spondyloarthropathies

Bone Infections Malignancies

Muscles

POLYMYOSITIS (HIV MYOPATHY)

Any stage of HIVPresents with

Bilateral proximal muscle weakness

Elevated CK levelsPathogenesis uncertainDiagnosis

Electromyography MRI Muscle biopsy (Nerve conduction

studies)Treatment limited

HAART Corticosteroids

PYOMYOSITiS Advanced HIV Presents with

Insidious muscle pain & swelling

With or without systemic symptoms

Requires prior muscle injury Imaging

CTMRISonar

TreatmentAnti-microbialsSupportiveSurgery

NRTI MYOPATHY

Long term useDose-related mitochondrial toxicity

Prevalence 17%Clinical picture

Similar presentation to polymyositisKeep lactic acidosis in mind

ManagementDiscontinuation

Joints

Related to HIV virus

ARTHRALGIA

Early disease Acute HIV syndrome

Most patients seek medical attentionFever, fatigue, maculopapular rash50-70% myalgias, arthralgias, paresthesias

Painful Articular Syndrome10% of HIV patients

ACUTE SYMMETRIC POLYARTHRITIS

Resembles rheumatoid arthritis Characterized

Swan neck deformities Ulnar deviation of the hand & digits Radiographic results

Non erosive Differentiation from RA

Atypical onset RF usually negative (may be low positive

with HIV) Anti-CCP negative in HIV

Treatment HAART Symptomatic Corticosteroids Chloroquin

HIV ASSOCIATED ARTHROPATHY

Acute asymmetric oligoarthritis (Occurs late)Resembles reactive arthritisPresents

Acute severe painLarge joints6 weeks to 6 monthsNegative HLA B27 and RF

TreatmentHAARTSymptomaticCorticosteroids

Opportunistic infections and other auto-immune diseases

REITERS SYNDROME (Reactive arthritis)

Prevalence controversial 5-10%Pathogenesis

HLA B27 positivity (more susceptible)

Clinical picture “Incomplete” Reiter’s syndrome Assymetrical arthritis and enthesopathies Extra-articular manifestations

TreatmentHAARTSymptomaticCorticosteroidsSalazopyrin

PSORIATIC ARTHROPATHY

Prevalence 3%10-40 X more frequent

in HIV infected patientsClinical picture

resembles psoriasis in the general population but may be more severe

HYPERTROPHIC OSTEOARTHROPATHY

Associated with PCP Bronchus Ca

Clinical picture Severe pain in lower extremity Clubbing Arthralgias/periarticular soft tissue inflammation Non-pitting oedema

Special investigations Radiography

Periosteal reaction Scintigraphy Inflammation of distal ends of long bones

Treatment Underlying cause

AVASCULAR NECROSIS AVN and HAART

Possible link HIV related risk factors

Corticosteroid Megestrol Hyperlipidemia Pancreatitis

Non HIV related risk factors Alcoholism Hypercoagulability Smoking

Common sites Femoral head Humeral head Lunate (Kienbock disease) Scaphoid (Preiser disease)

Musculoskeletal infections in HIV

Septic ArthritisTuberculosis

OsteomyelitisBacillary

AngiomatosisToxoplasmosis

Other conditions affecting the musculoskeletal system in HIV

Non-Hodgkin Lymphoma

Rhabdomyolysis

Myesthenia Gravis

Nemaline (Rod) myopathy

Fibromyalgia

Important concepts in HIV and the musculoskeletal system

Concerning the HIV infection HIV modifies the presentation, clinical picture and outcome of auto-immune

diseases HIV infection may mimic many auto-immune diseases Auto-antibodies may be present in both HIV (low titers) and auto-immune

diseases Considering immune suppression

HIV-virus more responsible for manifestations in early disease Opportunistic infections and malignancies more prominent in late disease

Concerning the drugs The drugs used to modify auto-immune disease may modify the outcome of

HIV infection HAART may present with musculoskeletal adverse events Drug interactions must always be considered

Associated conditions Same principles of diagnosis and management apply as in patient without HIV

(after consideration of the above)

Principles for management

Musculoskeletal syndromes in HIV may be unrelated to HIV infection

Treat the underlying cause if possibleRule out or correctly diagnosis infections

Probability of opportunistic infection depends on stage of HIVConsider HIV related medications in differential

diagnosisHigh threshold when using immunosuppressive drugs

Acute monoarthritis

Pitfalls Septic Joint

Acute Monoarthritis is a rheumatologic emergency

Infection may destroy a joint in 48 hours

Septic ArthritisViralBacterial

Gram positive Gram negativeNeiseria (GC, MC)AnaerobicMycobacteria

Fungal

Septic Arthritis (Risk factors)

Immunosuppression (drugs, HIV)Intravenous Drug AbuseAbnormal joint (increased risk for septic arthritis)

• OA• RA• Prosthesis

Remote infectious source

Patient with monoarticular complaint

Complete history and Physical examination

Careful examreveals

poliarticular arthritis

Periarticularsyndrome

Tendinitis,bursitis, strain,

sprain,osteomyelitis, soft tissue rheumatism

True monoarticulararthritis

Significant trauma orfocal bone pain? Radiograph

Fracture,avulsion

OA, CPPD

Acute changes

Chronicchanges

Yes

Effusion or inflammation?

Arthrocentesis

Yes

CBC, ESR, physical exam

Ultrasound-guidedaspiration or

CT/MRI

Severesymptoms

No

Arthrocentesis

Synovial fluidWBC > 5000

Acute inflammatoryarthritis

Synovial fluidWBC < 1000

Non-inflammatoryarthritis(OA, internal derangement)

Synovial fluidbloody

MRI

Arthroscopy

Internal derangement

Occult fracture,tumor, internalderangement

Acute inflammatory arthritis(synovial fluid WBC > 5000/cm3)

Gram stain Infection

Crystalexam

Gout, CPPDr/o superinfection

CBC, ESR, RF,ANA, Ricketsae

Systemic toxicity?

Empiric antibioticsx24 hours, awaiting

cultures

Young: GC > staph >strepOld: staph > strep > GCImmunocompromised:Staph, gram-negative,other unusual organisms

CPPD, reactive arthritis,systemic rheumatic disease

Anti-inflammatory medication;Follow-up in 24-48 hours;Re-aspirate joint if worsens

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Infected joint in RA

Back

TUBERCULOSISPott’s disease

Involvement of bone and discs with collapse of vertebrae

TUBERCULOSISMonoarthritis and Tendosynovitis

Destructive joint diseaseMonitor for extra-articular TB