Rheumatic Complications of Human Immunodeficiency Virus Infection in the Era of Highly Active Antiretroviral Therapy: Emergence of a New Syndrome of Immune Reconstitution and Changing Patterns of Disease
Section snippets
Part 1. Case Report
A 39-year-old homosexual man was diagnosed with HIV in March 2003 after 2 months of generalized weakness and vertigo culminating in cranial nerve VII and VIII shingles (Ramsey–Hunt syndrome) and resulting in right peripheral cranial nerve VII palsy. His past medical history was remarkable only for migratory superficial thrombophlebitis in the remote past. There was no family history of connective tissue disease; however, he has a twin sister with ulcerative colitis. At the time of HIV diagnosis
Methods
We performed a computer-based search from 1996 to 2004 (MEDLINE, National Library of Medicine, Bethesda, MD). Keywords used in the search were as follows: HAART, antiretroviral therapy (highly active), autoimmunity, lupus, arthritis (rheumatoid), arthritis (psoriatic), arthritis (reactive), systemic lupus erythematosus, connective tissue disease, vasculitis, sarcoidosis, prednisone, HIV-1, HIV infections, anti-HIV agents, immune reconstitution, acquired immunodeficiency syndrome,
Results
Table 1 describes all cases of noninfectious autoimmune complications to have presumably occurred as a consequence of immune reconstitution as a result of HAART (10, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39). Of the 31 cases reported, sarcoidosis appears to be the most common, followed by autoimmune thyroid disease, and then various forms of inflammatory arthritis and connective tissue disease. Given that this entity has not been clinically described in any
Patients and Methods
Beginning in September 1989, all HIV-infected patients seen in the Clinical Immunology Department of the Cleveland Clinic Foundation were enrolled in a prospective study of potential manifestations of rheumatic disease. Each patient underwent a baseline history and physical examination and a detailed rheumatologic evaluation by a rheumatologist (L.H.C.). Only patients seen and evaluated for primary treatment of their underlying HIV disease were enlisted; all patients referred for the expressed
Results
The demographics of the overall study group, including age, sex, and HIV risk behaviors, are stated in Table 2. Among the 395 HIV-infected subjects enrolled in the study, 57 were already receiving follow-up care at the time the prospective study was initiated in 1987 (follow-up 0 to 61 months); thus these patients were studied both retrospectively and prospectively. The remaining 338 patients were studied only during the prospective phase of the study. The mean duration of known HIV infection
Discussion
Since the beginning of the epidemic of HIV/AIDS in the early 1980s much has been written about rheumatic complications. Numerous case reports and clinical series from both Western industrial as well as underdeveloped countries have helped define a spectrum of disease that while clinically uncommon often displays distinctive features. The vast majority of these reports arose in the era before HAART became the standard of care (ie, before late 1995). Differentiating infectious and autoimmune
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