REVIEW Rheumatologic Manifestations of Infection with Human Immunodeficiency Virus (HIV) Brian R. Kaye, MD Purpose: To review the various rheumatologic manifesta- tions of human immunodeficiency virus (HIV) infection and to discuss their potential pathogenic mechanisms. Data Identification: A literature search using MEDLINE (1981 to 88) and Index Medicus (1981 to 88) and review of references from all identified articles. Study Selection: All studies and case reports addressing arthritis, myopathies, vasculitis, the sicca syndrome, system- ic lupus erythematosus, and autoimmune phenomena in HIV-infected patients are cited. Results of Data Synthesis: The Reiter syndrome and other reactive arthritides are the commonest arthritides seen in HIV-infected patients. Psoriatic arthritis and septic arthritis with opportunistic agents, as well as an articular pain that is severe, acute, and intermittent, may also occur with HIV infection. An arthritis that may be specific for the acquired immunodeficiency syndrome (AIDS) has been described. Myopathies, especially of a polymyositic type, vasculitis, and the sicca syndrome are also part of the spectrum of rheuma- tologic presentation of HIV infection. Several autoimmune phenomena, such as antinuclear and anticardiolipin antibod- ies, as well as- lupus anticoagulant, have been reported in HIV-infected patients. Conclusions: The Reiter syndrome, reactive arthritis, pol- ymyositis, and the sicca syndrome may herald the onset of clinically evident HIV infection. These diseases and others may also occur in patients with full-blown AIDS. Further- more, HIV infection may mimic systemic lupus erythemato- sus. Almost 50 000 cases of the acquired immunodeficien- cy syndrome (AIDS) had been reported in the United States by the end of 1987 (1), and it is estimated that one and a half million people in the United States have been infected with human immunodeficiency virus (HIV) (2, 3). There are many different manifesta- tions of HIV infection, and reviews have focused re- cently on the neurologic (4-6), ocular (7, 8), oral (9), dermatologic (10, 11), gastrointestinal (12-14), pul- monary (15), and renal (16) manifestations of HIV infection. In addition, there may be musculoskeletal involvement in as many as 72% of the patients infect- ed with HIV (17). This review focuses on the rheuma- tologic manifestations of HIV infection. These mani- festations include arthritis and arthralgia, myositis, vasculitis, the sicca syndrome, and relevant autoim- mune phenomena (Tables 1 and 2). Possible patho- genic mechanisms of such manifestations are explored. Finally, systemic lupus erythematosus and the similar- ity of its presentation to that of HIV infection are dis- cussed. The Reiter Syndrome and Reactive Arthritides Infection with HIV has been associated with several types of arthritis, the most frequently reported types being the Reiter syndrome and reactive arthritis. Of 101 patients with HIV infection seen at the University of South Florida, 10 patients had the Reiter syndrome (17). Solomon and associates (18) found 3 patients with the Reiter syndrome in a prospective study of 50 consecutive patients seen at an HIV clinic, and they also identified 9 patients with the Reiter syndrome in a retrospective chart review of 40 hospitalized patients with HIV infection who also had arthritis or psoriasis. These data show a far greater prevalence of the Reiter syndrome in HIV-infected patients than the 0.06% prevalence found in men (20 to 29 years old) from Rochester, Minnesota (19). A total of 51 HIV-infected patients with the Reiter syndrome or reactive arthritis have been reported in detail (17, 20-25) (Table 3.) These patients had pre- dominantly a severe, persistent oligoarticular arthritis primarily affecting the large joints of the lower extrem- ities (17, 20-25). A few patients had sacroiliitis (17, 20, 23). Many patients also had other clinical features, such as urethritis, conjunctivitis, keratodermia blen- norrhagicum, circinate balanitis, and painless oral ul- cers (17, 20-25), thus fulfilling diagnostic criteria for the Reiter syndrome (26). Other patients lacked these nonarticular clinical features and would be classified as having reactive arthritis (27). Annals of Internal Medicine. 1989;111:158-167. From Santa Clara Valley Medical Center, San Jose, Califor- nia. For current author address, see end of text. 158 ©1989 American College of Physicians Downloaded From: http://annals.org/ by Brian Kaye on 01/04/2015