HIV/AIDS (musculoskeletal manifestations)

Musculoskeletal manifestations of HIV/AIDS are not as common as CNS or pulmonary complications. Nonetheless, their prevalence is high. 

Pathology

Depending on the condition, aetiology may be related to the HIV infection itself, the resultant immunodeficiency, or highly-active antiretroviral therapy (HAART).

Infection

Infection is common in HIV patients, particularly those with low CD4 counts, and concomitant intravenous drug use. 

Manifestations include:

• soft tissue infections: cellulitis, necrotizing fasciitis, abscess formation and pyomyositis
• osteomyelitis 
  • the most common bacterial pathogen is S. aureus. 
  • tuberculous osteomyelitis is observed with increasing frequency in this population
  • bacillary angiomatosis is uncommon but specific to the HIV-infected population ^2,3
• septic arthritis: likely related to the prevalence of concomitant intravenous drug use​
• septic bursitis ¹

Arthritides

• HIV: associated arthritis/arthralgia ^1,4,5 
  • may result from the direct infection of the joint by the HIV virus  
  • usually, this is a self-limiting  mono- or oligoarthropathy, lasting 1-6 weeks
  • tends to affect large joints of the lower limb
  • radiographs are typically normal or demonstrate a joint effusion 
  • less commonly, there is chronic, erosive arthritis with joint space narrowing
• reactive arthritis: may present with an incomplete clinical form of the disease, but radiographic features are the same as in non-HIV infected individuals
• psoriatic arthritis: higher prevalence than in the non-HIV affected population
• undifferentiated spondyloarthritis with clinical features of both Reiter’sreactive and psoriatic arthritisarthritides
  • possibly the most common form ⁴
  • radiographic findings include osteoporosis, soft-tissue swelling, bone erosions and periosteal reaction
• rheumatoid arthritis and SLE may improve or remit in the setting of HIV infection

Neoplasms

• Kaposi sarcoma
• lymphoma

Miscellaneous

• osteonecrosis: increased risk is due to HIV infection itself, use of high-dose corticosteroids and antiretroviral therapy
• osteoporosis ⁹
  • ​high prevalence observed in HIV: 3 x rate in non-HIV patients
  • antiretroviral drugs associated with demineralisation, although HIV per se is associated with osteoporosis 
• hypertrophic pulmonary osteoarthropathy (HPOA)
• fat redistribution syndrome: associated with HAART