Edema in HIV: how does it manifest itself and how to eliminate it? Infectious viral arthritis Diseases of the joints due to HIV infection.

Very often, the presence of the immunodeficiency virus in the body provokes the development of concomitant diseases. The most unpleasant symptoms arise with the development of AIDS. The fact that HIV has entered the active stage may be indicated by:

• elevated cholesterol levels;
• a large amount of sugar in the blood;
• high blood pressure;
• increased triglyceride levels.

In rare cases, patients complain of pain in muscles and joints, swelling of the legs. Such reactions of the body are completely understandable and expected.

However, you need to understand that with HIV, leg swelling can occur due to factors independent of the virus (for example, poor diet, pregnancy, or kidney disease). But with AIDS, protein-free edema most often occurs, which is provoked by a lack of protein in the diet.

Causes of swelling of the legs with HIV

The immunodeficiency virus causes the human body to produce many antibodies, white cells, and circulating immune complexes that attack foreign organisms and affected tissues. Typically these antibodies only target infectious organisms, but with HIV they can also attack healthy tissue. For this reason, joint pain and swelling of the legs occur. Most often, edema (including protein-free edema) occurs in men over 50 years of age who have necrotizing retinitis and regularly take Kaletra.

Treatment and prevention of leg swelling due to AIDS

Non-protein edema in AIDS is treated with non-steroidal anti-inflammatory drugs such as ibuprofen or naproxen.

But if the swelling lower limbs the patient is accompanied by shortness of breath, then prevention of heart failure and anemia is necessary. A diuretic (for example, furosemide, no more than 40 mg per day) will help. If protein-free edema is accompanied by exhaustion, then the patient is prescribed a blood transfusion, namely red blood cells.

Currently connected antiviral drugs and edema has not been officially confirmed. Therefore, there are no special prevention methods for HIV-infected people. However, immediately after swelling occurs, you need to consult a doctor who will adjust the course of antiviral drugs and try to eliminate the problem. You will also have to refuse oral contraceptives, any synthetic hormones, calcium channel blockers, antidepressants and MAO inhibitors, which are often prescribed to AIDS patients.

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Joint damage in HIV and AIDS is the main symptom of the influence of infection on the patient’s body. These are irreversible processes, the treatment of which is to reduce pain and swelling of the tissues, and prevent tendon deformation. Men are more at risk of developing infectious arthritis than women. At the same time, other symptoms of HIV appear. Therapy for the musculoskeletal system must be consistent with general treatment; for this it is important to fully follow the instructions of the treating doctor.

Why and where do they hurt?

Reasons why joint pain appears in HIV-infected patients:

• disorganization of the work of lymphocytes;
• provoked inflammation;
• the appearance of infectious arthritis;
• increasing the risk of tumor appearance and enlargement;
• disruption of blood circulation in bone tissue and joints.

The immunodeficiency virus provokes a painful syndrome in the joints, muscles and aching bones. Decreasing immune system and the body becomes more susceptible to the appearance of pathologies of the musculoskeletal system.

The pain appears due to the intensification of such ailments that are aggravated by HIV:

HIV increases the symptoms of other diseases, such as osteoporosis.

• joint arthralgia;
• arthritis caused by infection (psoriatic, septic and reactive);
• polymyositis;
• osteoporosis;
• osteonecrosis;
• tuberculosis;
• rheumatological diseases.

Pain in the joints due to lesions of the musculoskeletal system manifests itself already in the initial stages of HIV and accompanies the disease at all stages of development. The pain is aching, long-lasting (for days), worsening the comfort of a person’s life. Often appears at night. Large joints are most affected motor system(elbow, shoulder and knee). In this case, several affected areas may be observed, the back and neck suffer. Symmetrical and asymmetrical lesions are observed.

What to do about the problem?

Pick up effective treatment Only the attending physician can.

It is impossible to restore damaged joint tissue with HIV. The main goal of therapy is to stop pain syndrome, alleviate the patient’s condition and stop the destruction of joint structures. Self-treatment unacceptable. Only the attending physician, who knows the complete clinical picture of the patient, has conducted extensive diagnostics and monitors the medications the patient is taking in parallel, can prescribe a therapy method and medications. With the help of painkillers, analgesics and anti-inflammatory drugs, it will be possible to temporarily eliminate painful sensations, but not to get rid of the pathology. Ignoring degenerative changes will accelerate the course of the disease, complicate the disease and lead to irreversible pathological processes in the joints.

Compresses, infusions, teas, ointments from traditional medicine do not give significant results. They help enhance action traditional therapy, increase the overall functionality of the body, improve the elasticity of joints. When used independently, products from herbal components do not have the necessary therapeutic effect. It is better to use topical medications that penetrate the injured joint faster. The name of the medication and the dosage regimen are determined by the doctor. It is important to comply proper nutrition, drink the amount of clean water recommended by your doctor, avoid heavy physical activity and balance your work and rest schedule.

More than half of HIV-infected people have joint diseases. Initially, symptoms reminiscent of rheumatoid arthritis appear. The disease develops from 5 days to 2 months. In this case, under the influence of a severe autoimmune disorder, the patient’s condition worsens, which requires immediate medical intervention.

Types of arthritis in HIV

Under the influence of severe immunodeficiency, rheumatic disorders are observed in human joints, which provoke the development of many diseases. With HIV infection, aching pain appears, which is often perceived as a manifestation of neuropathy. Only after large joints begin to swell and pain increases does a suspicion arise about the development of a disease such as arthritis. Under its influence occur degenerative lesions inflamed areas.

HIV-associated arthritis

Inflammation of the tendon provokes severe pain when walking.

The disease has a rather complex clinical picture. The disease affects the upper and lower extremities, which leads to swelling of the fingers. The Achilles tendons are involved in the pathological process. In this case, severe swelling and increasing pain are noted. As the disease progresses, dryness and flaking of the skin in the affected areas may appear. In more severe cases, inflammatory processes of the mucous membranes of some organs are observed. The genitourinary system is especially affected.

HIV-associated reactive arthritis

With this type of disease, it is impossible to determine the presence of a pathogenic infection in the joints, which complicates the diagnosis process. The first signs appear already in the second week after infection. The phalanges of the lower fingers and upper limbs, joints hurt. The tendons suffer, which is manifested by swelling and severe pain. When complications occur, an inflammatory process develops on the mucous membranes of organs. Treatment consists of special non-steroidal drugs and primary therapy aimed at combating arthritis. With this disease, the following symptoms are noted, which are localized in the legs:

• joint pain (in the morning when trying to move);
• swelling of the affected areas;
• inflammation lymph nodes due to impaired blood flow;
• redness of the skin;
• inflammation of periarticular structures.

Reiter's syndrome

The nail plate thickens.

The pathology can develop several years before infection and manifest itself only under the influence of active antibodies to the autoimmune disease. The attachment points of the tendon and ligaments are damaged. The disease leads to deformation of the nail plate and damage to the skin. It has a chronic course with periodic remissions. The exacerbation occurs against the background of an illness of moderate severity. The development of erosive arthritis leads to disability. To achieve a good therapeutic effect, in addition to standard drug treatment, physical rehabilitation means are used.

Reiter's syndrome leads to the development of concomitant diseases such as conjunctivitis and stomatitis.

HIV-associated psoriatic arthritis

Skin manifestations of the disease are observed in 15% of patients. They mainly accompany the articular manifestations of the disease. Less often they occur during remission of the underlying disease. Signs include redness of some areas of the skin and rashes. With the active development of the disease, the formation of erosions is observed, which is characteristic of psoriasis. When palpating the affected areas, severe coarsening and thickening of the skin is noted, not accompanied by pain. The condition indicates the development of a dangerous infection. Treatment comes down to the use of special therapy, massage, therapeutic exercises and physiotherapy.

The most complete answers to questions on the topic: “Can joints hurt with HIV? Treatment.”

People infected with the immunodeficiency virus quite often experience pain of various etiologies.

In order to understand why this or that part of the body hurts with HIV, you need to determine the cause of this symptom. According to statistics, in almost half of those infected with AIDS, discomfort is associated precisely with the disease itself, while for the rest they are a consequence of treatment or are in no way related to the infection at all. So, what pains with HIV most often bother a patient?

There are psychological (fear of death, inability to enjoy life, heightened sense of guilt) and physical pain. The latter include:

• head;
• localized in the abdomen and chest;
• V upper sections Gastrointestinal tract: oral cavity, pharynx and larynx;
• joint and muscle.

What muscles hurt with HIV?

If muscles ache with HIV, this indicates tissue damage by the pathogen. This condition occurs in 30% of infections. The mildest form is simple myopathy. The most severe is disabling polymyositis. It develops quite early, so it is often considered one of the first signs of the disease. However, even with myopathy, performance is greatly reduced. How do muscles hurt with HIV? Characteristic are aching discomfort that does not get stronger or weaker. It should be noted that back and neck pain cause the most inconvenience to a person. With HIV, this is a normal phenomenon, which, however, greatly interferes with a full life. Muscle pain due to HIV can be stopped, but it is necessary to understand that the damaged tissue can hardly be restored. Analgesics have been successfully used for this purpose. The most effective are intramuscular injections.

Joint pain with HIV

Every infected person has wondered at least once: do joints hurt with HIV? The fact is that this kind of manifestation is usually attributed to other ailments. However, it is the most common symptom. Occurs in more than 60% of AIDS patients. Such pains are really very well disguised as rheumatism, which is why anthropopathy itself is often called rheumatic syndrome.

Most often with HIV, large joints hurt, such as:

• elbow;
• knee;
• brachial.

Such pains are not constant and last no more than a day. They go away on their own, without additional interventions. They occur due to impaired blood circulation in the bone tissue. Very often, unpleasant sensations are felt in the evening or at night, much less often during the day.

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There are two main signs that will help detect a connection between human immunodeficiency virus infection and joint pain:

• Damage to small joints, e.g. intervertebral discs. This condition is called undifferentiated spondyloarthropathy.
• The presence of several rheumatoid diseases simultaneously in one patient - combined spondyloarthritis.

Both of these indicate a direct relationship between pain and infection. Joint damage can occur as follows:

• Asymmetrical damage to large joints (mainly the lower extremities), accompanied by severe pain, usually associated with necrosis of bone tissue.
• Symmetrical arthritis, which develops quickly and is very similar to rheumatism. Most often it occurs in men and is accompanied by damage to various joints and their groups.

Thus, pain during HIV infection occurs quite often and its intensity varies. Unfortunately, you can only get rid of the symptom for a while, but it is impossible to eliminate the damage itself.

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Damage to the musculoskeletal system due to HIV infection

… in 30-70% of cases, pronounced clinical polymorphism of HIV infection includes rheumatological manifestations.
Arthralgia is the most common rheumatic manifestation of HIV infection; in this case, the pain is usually mild, intermittent, has an oligoarticular type of lesion, and primarily affects the knee, shoulder, ankle, elbow and metacarpophalangeal joints. In some cases, but more often in the later stages of the disease, severe pain in the joints of the upper and lower extremities (usually in the knee, elbow and shoulder joints) may occur, lasting less than 24 hours.
HIV-associated arthritis is similar to arthritis that develops in other viral infections, and is characterized, as a rule, by subacute oligoarthritis with damage (predominantly) to the joints of the lower extremities in the absence of soft tissue pathology and association with HLA B27. Inflammatory changes are not detected in the synovial fluid. When radiography of joints, pathological symptoms are usually not detected. As a rule, spontaneous relief of articular syndrome is observed.
HIV-associated reactive arthritis is characterized by typical symptoms of seronegative peripheral arthritis with predominant damage to the joints of the lower extremities, the development of severe enthesopathies, as well as plantar fasciitis, Achilles bursitis, dactylitis (“sausage fingers”) and severe limitation of patient mobility. Vivid extra-articular manifestations are noted (keratoderma, annular balanitis, stomatitis, conjunctivitis), detailed symptoms of the HIV-associated complex in the form of low-grade fever, weight loss, diarrhea, lymphadenopathy. Damage to the musculoskeletal system of the body is not typical. The course is usually chronic and relapsing. HIV-associated reactive arthritis can occur more than two years before the diagnosis of HIV infection or against the background of the onset clinical manifestations AIDS, but most often manifests itself during the period of already existing severe immunodeficiency.
HIV-associated psoriatic arthritis is usually characterized by rapid progression of joint manifestations, and a correlation between the severity of skin and joint damage. Remember: any patient with a severe attack of psoriasis or a form of the disease that is resistant to conventional therapy should be tested for HIV infection.
HIV-associated polymyositis develops quite early and may be one of the first manifestations of muscle damage. Its main manifestations are similar to those in idiopathic polymyositis: myalgia, weight loss, weakness of proximal muscle groups, increased serum CPK, the electromyogram is characterized by a myopathic type of changes in the form of: myopathic action potentials of motor units with early activation and complete low-amplitude interference; fibrillation potentials, positive sharp waves. Muscle biopsy reveals signs of inflammatory myopathy: inflammatory infiltration of the perivascular and interstitial area around myofibrils in combination with their necrosis and repair.
Nemaline myopathy is characterized by muscle weakness, hypotonia of the muscles, which first appear in the pelvic girdle, then in the muscles of the shoulder girdle, and then become generalized as the disease progresses. When examining muscle fiber biopsies under a light microscope, nemaline bodies are revealed in the form of rod-shaped or thread-like inclusions located under the sarcolemma or in the thickness of the muscle fiber.
Myopathy in “HIV-related cachexia” is diagnosed when the following criteria are met: weight loss of more than 10% of baseline, chronic diarrhea (>30 days), chronic fatigue and documented fever (>30 days) in the absence of other causes.
Septic arthritis as part of HIV infection usually develops in intravenous drug users or with concomitant hemophilia. The main causative agents of septic arthritis are gram-positive cocci, Haemophilus influenzae, and salmonella. The disease manifests itself as acute monoarthritis, predominantly of the hip or knee joint. Possible damage to the sacroiliac, sternocostal or sternoclavicular joints. In general, HIV infection does not have a significant effect on the course of septic lesions of the musculoskeletal system, which (complications), as a rule, are successfully cured with adequate antibacterial therapy and timely surgical intervention.
Tuberculous spondylitis, osteomyelitis, arthritis. Tuberculosis is one of the most common life-threatening HIV-associated opportunistic infections. At the same time, lesions of the musculoskeletal system account for 2% of cases. (!) The most common localization of the tuberculosis process is the spine, but there may be signs of osteomyelitis, mono- or polyarthritis. Unlike classical Pott's disease, tuberculous spondylitis as part of HIV infection can occur with atypical clinical and radiological symptoms (mild pain, lack of involvement of intervertebral discs in the process, the formation of foci of reactive bone sclerosis), which leads to delays in diagnosis and timely treatment. Damage to the osteoarticular system by atypical mycobacteria usually develops in the later stages of HIV infection, when the level of CD4 lymphocytes does not exceed 100/mm3. Among the pathogens of this group, M. haemophilum and M. kansasii predominate. In this case, several foci of infection are noted, and manifestations such as nodules, ulcers and fistulas are observed in 50% of patients.
Mycotic joint damage in HIV-infected patients. The main pathogens are Candida albicans, Sporotrichosis schenkii and Penicillium marneffei (in southern China and Southeast Asia). Infection with the fungus Penicillium marneffei occurs in the late stages of HIV infection and occurs with fever, anemia, lymphadenopathy, hepatosplenomegaly, acute mono-, oligo- or polyarthritis, as well as multiple subcutaneous abscesses, skin ulcers, fistulas and multifocal osteomyelitis.
The diagnosis of musculoskeletal infection in patients with HIV infection may be difficult due to the following reasons: (1) absence of leukocytosis in peripheral blood and synovial fluid, especially in the later stages of HIV infection; (2) atypical location of the lesion; (3) pathogens isolated from the joint and from the blood may be different in case of polymicrobial etiology of the lesion; (4) problems with pathogen identification in the presence of previous antibiotic treatment; (5) erasure of symptoms in the later stages of HIV infection, when signs of damage to other organs and systems come to the fore in the clinical picture.
It is necessary to remember the possibility of developing rheumatological syndromes in association with antiretroviral therapy, for example, zidovudine myopathy syndrome. This syndrome has an acute onset of myalgia, muscle tenderness and proximal muscle weakness after an average of 11 months. from the start of treatment. Characterized by increased concentrations of muscle enzymes in the blood serum and a myopathic type of EMG. When examining a biopsy of muscle tissue, a specific toxic mitochondrial myopathy is revealed with the appearance of “torn red fibers,” reflecting the presence of pathological mitochondrial crystalline inclusions. Cessation of treatment leads to an improvement in the patient's condition. Creatine kinase levels return to normal within 4 weeks, and muscle strength is restored within 8 weeks of discontinuation of the drug.
The use of protease inhibitors can lead to rhabdomyolysis (especially in combination with statins), as well as lipomatosis of the salivary glands. Cases of the development of adhesive capsulitis, Dupuytren's contracture and dysfunction of the temporomandibular joint have been described during treatment with indinavir.
Osteonecrosis and other types of bone tissue damage (for example, osteopenia, osteoporosis) are widespread among HIV-infected patients, which is due both to the disease itself and to the antiretroviral therapy performed. The most common localization of aseptic necrosis is the head femur, the lesion of which (in the absence of complaints) was detected using magnetic resonance imaging in more than 4% of HIV-infected patients. Aseptic necrosis femoral head in 40-60% of cases is bilateral, and can also be combined with osteonecrotic lesions of another localization (head humerus), femoral condyles, scaphoid and lunate bones, etc.). As the disease progresses, in more than 50% of cases there is a need for surgical treatment– prosthetics hip joint.

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Rheumatological diseases of the joints in HIV

Acquired immunodeficiency syndrome (AIDS) quite often leads to inflammation of the joints. Lesions of the musculoskeletal system occur in more than 60% of patients with HIV symptoms. The virus disrupts the normal work of lymphocytes to protect, in particular, joints. Bacteria easily penetrate defenseless joints and cause inflammation, as well as secondary infectious arthritis. The likelihood of developing tumors increases.

People with HIV symptoms also often experience pain in large joints (elbows, shoulders, knees). The pain does not last long and is explained by poor circulation in the bone tissue (especially at night).

Let us list some rheumatological manifestations of HIV symptoms:
– arthralgia of the knee, shoulder, ankle, elbow and metacarpophalangeal joints is the most common joint disease in HIV infection;
– HIV-associated arthritis is mild and similar to arthritis in other viral diseases joints;
– HIV-associated reactive arthritis can occur long before the first symptoms of HIV infection appear. But even during the period of full development, AIDS also appears quite often;
– psoriatic arthritis, which occurs when the body is infected by the HIV virus, develops very quickly, and there is a strong correlation between damage to the skin and joints. Remember an important rule: any patient with sudden onset psoriasis or a form of the disease that is resistant to traditional therapy must be checked for symptoms of HIV infection;
– polymyositis when infected with HIV can serve as a sign of the presence of the virus in the blood and joints, since its manifestations can be tracked quite early. Weight loss (weight loss of more than 10%), muscle weakness, muscle hypotonia (first manifested in the pelvic girdle, then in the muscles of the shoulder girdle), increased temperature for a long time, chronic diarrhea and constant chronic fatigue occur;
– septic arthritis in AIDS patients most often affects the group of “intravenous” drug users and is complicated in some cases by concomitant hemophilia. The most common infectious agents are salmonella, cocci and hemophilus influenzae. The immunodeficiency virus, as a rule, does not have a significant effect on the course of septic lesions. The prognosis with appropriate and adequate antibacterial therapy is favorable;
– tuberculosis, as the most common opportunistic infection when infected with HIV, can lead to tuberculous spondylitis, osteomyelitis and arthritis. Most often it is localized in the spine, occurs atypically (without pain and involvement of intervertebral discs), which leads to delays in diagnosis;
– mycotic damage to joints during HIV infection, as a rule, occurs in the later stages of the disease and is very severe. Anemia, lymphadenopathy, acute polyarthritis and multiple subcutaneous abscesses, fistulas and ulcers are common...
– the development of rheumatological syndromes in the treatment of AIDS is sometimes due to individual perception of the medications used in antiretroviral therapy. For example, there is a syndrome of “zidovudine” myopathy. It is quite acute and is expressed in muscle soreness, myalgia and muscle weakness. This complex of symptoms appears approximately 11 months after the start of treatment. Discontinuation of treatment leads to an improvement in the patient's condition, for example, muscle strength is restored after 8 weeks of stopping treatment against AIDS;
– Osteoporosis and osteonecrosis are common in people with symptoms of HIV infection. Most often, aseptic necrosis of the femoral head (and the head of the humerus) is diagnosed, which leads to the need for surgical treatment. In approximately 50% of cases, hip replacement replacement is necessary.

For quotation: Belov B.S., Belova O.L. HIV infection: rheumatological aspects // Breast cancer. 2008. No. 24. S. 1615

At the beginning of the 21st century, infection caused by the human immunodeficiency virus (HIV) still remains one of the most important medical and social problems. According to WHO, in 2007 there were 33.2 million people living with HIV in the world. At the same time, HIV infection was the cause of 2.1 million deaths. About 2.5 million new cases of HIV infection are diagnosed annually, mainly in the countries of Central and East Asia and Africa (especially in the Sahara Desert region).

In Russia as of December 31, 2007 total number officially registered cases of HIV infection amounted to 403,100 (including 2,636 among children). Acquired immunodeficiency syndrome (AIDS) was diagnosed in 3639 patients. However, given that the AIDS stage does not begin until several years after transmission of the virus, the reported number of HIV-positive people is only a fraction of the actual number of infected individuals both in Russia and throughout the world.
HIV is an RNA virus, belongs to the retrovirus family and contains a number of enzymes - reverse transcriptase (revertase), integrase and protease. HIV infects differentiated cells of the macroorganism that carry the CD4 receptor. When HIV penetrates into a cell, the viral RNA is reversed into DNA, which, in turn, is integrated into the DNA of the host cell, remaining there for life (DNA provirus). Subsequently, under the influence of a number of factors, activation of HIV infection occurs with progressive damage to the above cellular structures. As the disease progresses, autoimmune processes are launched, and resistance to secondary infections and tumors decreases. All this causes multi-organ damage and a variety of clinical symptoms.
Pronounced clinical polymorphism of HIV infection also includes various rheumatological manifestations, occurring in 30-70% of cases. The first reports of HIV-associated rheumatological syndromes appeared in the mid-1980s. and included descriptions of cases of polymyositis, vasculitis, reactive arthritis and Sjögren's syndrome (the latter later called diffuse infiltrative lymphocytic syndrome). To date, the range of described rheumatic syndromes associated both directly with HIV infection and with anti-retroviral therapy is very wide (Table 1).
Joint damage
Arthralgia is the most common (25-45%) rheumatic manifestation of HIV infection. The pain, as a rule, is mild, intermittent, has an oligoarticular type of lesion, affecting mainly the knee, shoulder, ankle, elbow and metacarpophalangeal joints. In 5-10% of cases (usually in the later stages of the disease), intense pain syndrome may occur, which lasts for ≤ 24 hours, characterized by severe pain in the joints of the upper and lower extremities (usually in the knees, elbows and shoulders), which often causes the need to use narcotic analgesics.
HIV-associated arthritis (3.4-10%) is similar to that developing with other viral infections and is characterized by subacute oligoarthritis with predominant involvement of the joints of the lower extremities in the absence of soft tissue pathology and association with HLA B27. Inflammatory changes are not detected in the synovial fluid. X-rays of the joints do not reveal any pathological symptoms. As a rule, spontaneous relief of articular syndrome is observed.
HIV-associated reactive arthritis (ReA) develops in 3-10% of cases. It can occur more than 2 years before the diagnosis of HIV infection or against the background of the onset of clinical manifestations of AIDS, but most often it manifests itself during the period of already existing severe immunodeficiency. Typical symptoms of seronegative peripheral arthritis are characteristic, with predominant damage to the joints of the lower extremities, the development of severe enthesopathies, plantar fasciitis, Achilles bursitis, dactylitis (“sausage fingers”) and a pronounced limitation of the patients’ mobility. There are pronounced extra-articular manifestations (keratoderma, annular balanitis, stomatitis, conjunctivitis), extensive symptoms of the HIV-associated complex (low-grade fever, weight loss, diarrhea, lymphadenopathy), frequent association with HLA B27 (80-90%). Damage to the musculoskeletal system of the trunk is not typical. The process often takes on a chronic, relapsing course.
The development of psoriasis (20%) is considered an unfavorable prognostic sign in HIV-infected patients, because it is a predictor of recurrent, life-threatening infections (primarily Pneumocystis pneumonia). In such patients, the entire spectrum of skin changes characteristic of psoriasis is revealed (exudative, pemphigoid, eczematous, pustular, etc.). Distinctive features of HIV-associated psoriatic arthritis include rapid progression of articular manifestations and a correlation between the severity of skin and joint damage. It is emphasized that any patient with a severe attack of psoriasis or a form of the disease that is resistant to conventional therapy should be examined for HIV infection.
Undifferentiated spondyloarthropathy (3-10%) manifests itself in the form of oligoarthritis, spondylitis, enthesopathies, dactylitis, onycholysis, balanitis, urethritis. However, symptoms are not enough to make a diagnosis of ReA or psoriatic arthritis. Duration - up to several months, often ending in disability.
Muscle involvement in HIV infection occurs in 30% of cases and ranges from uncomplicated myopathy and fibromyalgia or asymptomatic elevation of creatine phosphokinase levels to severe, disabling forms of polymyositis. HIV-associated polymyositis develops quite early and may be one of the first manifestations of the disease in question. Its main manifestations are similar to those in idiopathic polymyositis: myalgia, weight loss, weakness of proximal muscle groups, increased serum CPK, myopathic type of changes on the electromyogram (myopathic motor unit action potentials with early activation and complete low-amplitude interference, fibrillation potentials, positive sharp waves). A morphological study of muscle biopsy samples reveals signs of inflammatory myopathy: chronic inflammatory infiltration of the perivascular and interstitial area around myofibrils in combination with their necrosis and repair, as well as, compared with idiopathic polymyositis, a low content of CD4+ cells in endomysial infiltrates.
In nemaline myopathy, a fairly rare pathology in patients with HIV infection, muscle weakness and hypotension first appear in the pelvic girdle, then in the muscles of the shoulder girdle, and as the disease progresses they become generalized. When examining muscle fiber biopsies under a light microscope, the main defect is revealed - nemaline bodies in the form of rod-shaped or thread-like inclusions located under the sarcolemma or in the thickness of the muscle fiber.
Myopathy can be observed in HIV-related cachexia, the diagnostic criteria of which are weight loss of more than 10% of baseline, chronic diarrhea (>30 days), chronic fatigue and documented fever (>30 days) in the absence of other causes. .
More than 20% of HIV-infected people develop vasculitis affecting small, medium and large arteries. The leading syndrome in HIV-associated vasculitis is most often sensory-motor neuropathy.
Diffuse infiltrative lymphocytic syndrome (DILS) occurs in 3-8% of HIV-infected patients who are carriers of HLA DR6/7 (Caucasians) or DR5 (Negroids). It is characterized by the development of xerophthalmia, xerostomia, painless enlargement of the parotid glands, persistent lymphocytosis due to CD8 T lymphocytes and diffuse lymphocytic infiltration internal organs. The most serious complication is considered to be lymphocytic interstitial pneumonitis, which develops in 25-50% of patients with DILS. In approximately 30% of cases, palsy of the VIII pair of cranial nerves is observed, caused by mechanical compression by inflamed tissue salivary gland. Other neurological manifestations include aseptic meningitis and symmetric motor peripheral neuropathy. Within the framework of DILS, the development of lymphocytic hepatitis, polymyositis, interstitial nephritis, and type IV tubular acidosis is described. Unlike DILS, in Sjogren's syndrome: a) antibodies to Ro- and La-antigens are detected, b) cellular infiltration of the salivary glands is caused by CD4 T-lymphocytes, c) association with HLA B8 is much more common and DR3.
HIV-infected patients may develop a variety of clinical manifestations and laboratory phenomena that occur in systemic rheumatic diseases. Table 2 shows the so-called lupus-like manifestations of HIV infection. Along with the above, rheumatoid factor in this pathology is detected in 17% of cases, IgG - antibodies to cardiolipin - in 20-30%, and in the later stages of HIV - in 95%, antineutrophil cytoplasmic antibodies using indirect immunofluorescence or ELISA - in 18 and 43% cases accordingly. The presence of cell-specific antibodies, cryoglobulins (more often with concomitant hepatitis C), and an increase in the concentration of acid-labile interferon-a are described.
In light of the above, it should be remembered that in patients with active SLE, false-positive HIV test results (by ELISA or Westernblot) are possible, which become negative with clinical improvement. At the same time, HIV infection leads to the subsidence of immunopathological disorders in SLE and rheumatoid arthritis (RA) and aggravates the course of the disease in reactive urogenic arthritis and Lyme disease. These facts highlight the important role of CD4 T cells in the pathogenesis of SLE and RA compared with reactive arthritis and Lyme disease.
In reports from the early 1990s. the frequency of septic complications from the musculoskeletal system in this category of patients does not exceed 1%. However, in a recently published work by Spanish authors, the incidence of septic lesions in this location was 41%.
Septic arthritis as part of HIV infection usually develops in drug addicts who inject drugs intravenously or with concomitant hemophilia. The main pathogens are gram-positive cocci, Haemophilus influenzae, and salmonella. The disease manifests itself as acute monoarthritis, predominantly of the hip or knee joint. In “intravenous” drug addicts, damage to the sacro-sub-iliac, sternocostal and sternoclavicular joints is possible. The leading etiological agent of osteomyelitis and pyomyositis is Staphylococcus aureus. In general, HIV infection does not have a significant effect on the course of septic lesions of the musculoskeletal system. The latter, as a rule, can be successfully cured with adequate antibacterial therapy and timely surgical intervention.
Tuberculosis is one of the most common life-threatening HIV-associated opportunistic infections. At the same time, lesions of the musculoskeletal system account for 2% of cases. The most common localization of the tuberculous process in these patients is the spine, but there may be signs of osteomyelitis, mono- or polyarthritis. Unlike classical Pott's disease, tuberculous spondylitis as part of HIV infection can occur with atypical clinical and radiological symptoms (mild pain, lack of involvement of intervertebral discs in the process, the formation of foci of reactive bone sclerosis), which leads to delays in diagnosis and timely treatment. In this regard, many authors strongly recommend including these patients in the examination plan computed tomography and magnetic resonance imaging.
Damage to the osteoarticular system by atypical mycobacteria develops, as a rule, in the late stages of HIV infection, when the level of CD4 lymphocytes does not exceed 100/mm3. Among the pathogens of this group, M. haemophilum and M. kansasii predominate (50 and 25% of cases, respectively). In this case, several foci of infection are noted, and manifestations such as nodules, ulcers and fistulas are observed in 50% of patients.
The main causative agents of mycotic joint damage in HIV-infected patients include Candida albicans and Sporotrichosis schenkii. In southern China and Southeast Asia, the dimorphic fungus Penicillium marneffei is considered the leading etiological agent. Infection by this fungus usually occurs in the late stages of HIV infection and occurs with fever, anemia, lymphadenopathy, hepatosplenomegaly, acute mono-, oligo- or polyarthritis, multiple subcutaneous abscesses, the formation of skin ulcers and fistulas, and multifocal osteomyelitis.
The diagnosis of musculoskeletal infection in HIV-infected patients can be difficult for the following reasons: 1) the absence of leukocytosis in the peripheral blood and synovial fluid, especially in the later stages of HIV infection; 2) atypical localization of the lesion; 3) pathogens isolated from the joint and from the blood may be different in case of polymicrobial etiology of the lesion; 4) problems with identifying the pathogen in the presence of previous antibiotic treatment; 5) erasure of symptoms in the later stages of HIV infection, when signs of damage to other organs and systems come to the fore in the clinical picture.
It is necessary to remember the possibility of developing rheumatological syndromes in association with antiretroviral therapy. In particular, 1 year after the introduction of zidovudine, a drug from the group of nucleoside HIV reverse transcriptase inhibitors, into clinical practice, reports of “zidovudine” myopathy appeared in the literature. This syndrome is characterized by an acute onset with the development of myalgia, palpable muscle tenderness and proximal muscle weakness after an average of 11 months. from the start of treatment. Characterized by increased concentrations of muscle enzymes in the blood serum and a myopathic type of EMG. When examining a biopsy of muscle tissue, a specific toxic mitochondrial myopathy is revealed with the appearance of “torn red fibers,” reflecting the presence of pathological mitochondrial crystalline inclusions. Cessation of treatment leads to an improvement in the patient's condition. In this case, creatine kinase levels normalize within 4 weeks, and muscle strength is restored after 8 weeks. from the moment of drug withdrawal.
The use of protease inhibitors can lead to rhabdomyolysis (especially in combination with statins), as well as lipomatosis of the salivary glands. Cases of the development of adhesive capsulitis, Dupuytren's contracture and dysfunction of the temporomandibular joint have been described during treatment with indinavir.
Osteonecrosis, like other types of bone tissue damage (osteopenia, osteoporosis), is widespread among HIV-infected patients, which is due both to the disease itself and to the antiretroviral therapy performed. The most common location of aseptic necrosis is the head of the femur, damage to which (in the absence of complaints) was detected using magnetic resonance imaging in more than 4% of HIV-infected patients. Aseptic necrosis of the femoral head in 40-60% of cases is bilateral and can be combined with osteonecrotic lesions of another location (head of the humerus, femoral condyles, padiform and lunate bones, etc.). As the disease progresses, in more than 50% of cases, there is a need for surgical treatment - hip replacement.
Today, a combination of three or more antiretroviral drugs is used very actively and with sufficient success to treat HIV infection. This approach is called highly active antiretroviral therapy (HAART). It should be noted that in 1997-1998. Descriptions of cases of the development of cytomegalovirus retinitis and abscess infection caused by the M. avium intracellulare complex in HIV-infected patients who took HAART for several weeks appeared in the literature. Despite the differences in etiology, pathogenesis and localization of the lesion, in all these cases there was a pronounced inflammatory component, accompanied by an increase in the number of CD4 + cells and the restoration of an active immune response to the focal infection that existed before the start of HAART. To denote such reactions, the terms “inflammatory immune reconstitution syndrome” or “immune reconstitution syndrome” have been proposed. Moreover, within the framework of this syndrome, the development of systemic autoimmune diseases (SLE, RA, polymyositis) is described. This phenomenon may be due to both a weakening of the immunosuppressive effect of HIV infection on an existing autoimmune disease and the development of de novo disease.
To treat rheumatic pathology that has developed as part of HIV infection, the same medications are used as in HIV-negative patients. Among non-steroidal anti-inflammatory drugs, indomethacin is the drug of choice. In vitro studies have shown the ability of this drug to suppress HIV replication by 50%. Hydroxychloroquine has been successfully used for HIV-associated arthropathy. It is noteworthy that this drug, prescribed at a dose of 800 mg/day, was comparable in antiretroviral activity to zidovudine. The prescription of methotrexate, previously considered absolutely contraindicated, may be justified in patients with psoriasis and psoriatic arthritis developed as part of HIV infection, but this requires careful monitoring viral load and CD4+ cell counts. Development severe forms systemic vasculitis with damage to vital organs (lungs, kidneys, brain), as well as active SLE and polymyositis, is an indication for the prescription of glucocorticoids, possibly in combination with cytostatics with mandatory monitoring of the severity of immunosuppression.
Currently, experience is accumulating in the use of biological agents (primarily TNF-a-blockers) for the treatment of rheumatic pathology as part of HIV infection. There are reports indicating the effectiveness and fairly good tolerability of etanercept, infliximab and abatacept in RA, reactive and psoriatic arthritis, widespread psoriasis and Crohn's disease in combination with HIV infection. However, in some cases, drugs had to be discontinued due to the development of intercurrent infection. Most authors consider it necessary to continue research in this area in order to develop clearer indications for the use of the above drugs and methods for monitoring treatment in this category of patients.
Thus, the high incidence of the disease wide range symptoms, changing clinical picture under the influence of HAART, expanding possibilities for the use of antirheumatic drugs medicines(including biological agents) - all this indicates the high importance of the problem of HIV infection in modern rheumatology. A rheumatologist must have up-to-date information about various aspects of HIV infection and constantly maintain a high index of alertness in relation to this terrible disease.

Literature
1. Data on the website: www.who.int/mediacentre/news/2007/pr61/en/index.html
2. Data on the website: www.stopspid.ru/society/situation_in_russia/id.38/
3. Medina Rodriguez F. Rheumatic manifestations of human immunodeficiency virus infection. Rheum. Dis. Clun. North Am. 2003; 29: 145-161.
4. Colmegna I., Koehler J.W., Garry R.F., Espinoza L.R. Musculoskeletal and autoimmune manifestations of HIV, syphilis and tuberculosis. Curr. Opin. Rheumatol. 2006; 18: 88-95.
5. Reveille J.D., Williams F.M.. Rheumatologic complications of HIV infection. Best Pract. Res. Clin. Rheumatol. 2006; 20(6): 1159-1179.
6. Calabrese L.H. Rheumatic aspects of acquired immunodeficiency syndrome. Rheumatology. Eds. J.H. Kippel, D. A. Dieppe. Mosby Year Book Ltd. 1994; sect. 4: p. 7.1.-7.10.
7. Marquez J., Restrepo C., Candia L., Berman A., Espinoza L. Human immunodeficiency virus-associated rheumatic disorders in the HAART era. J. Rheumatol. 2004; 31: 741-746.
8. Belzunegui J., Santisteban M., Gorordo M., Barastay E, Rodriguez-Escalera C, Lopez-Dominguez L, Gonzalez C, Figueroa M. Osteoarticular mycobacterial infections in patients with the human immunodeficiency virus. Clin. Exp. Rheumatol. 2004; 22: 343-345.
9. Louthrenoo W., Thamprasert K., Sinsanthana T. Osteoarticular penicilliosis marneffei. A report of eight cases and review of the literature. Br. J. Rheumatol. 1994; 33: 1145-1150.
10. Louthrenoo W. Rheumatic manifestations of human immunodeficiency virus infection. Curr. Opin. Rheumatol. 2008; 20: 92-99.
11. Bessen L.J., Greene J.B., Louie E., Seitzman P., Weinberg H. Severe polymyositis-like syndrome associated with zidovudine therapy of AIDS and ARC. N Engl. J. Med. 1988; 318:708.
12. Florence E., Schrooten W., Verdonck K., Dreezen C., Colebunders R. Rheumatological complications associated with the use of indinavir and other protease inhibitors. Ann. Rheum. Dis. 2002; 61: 82-84.
13. Olive A., Salavert A., Manriquez M., Clotet B., Moragas A. Parotid lipomatosis in HIV positive patients: a new clinical disorder associated with protease inhibitors. Ann. Rheum. Dis. 1998; 57:749.
14. Allison G.T., Bostrom M.P., Glesby M.J. Osteonecrosis in HIV disease: epidemiology, etiologies, and clinical management. AIDS. 2003; 17:1-9.
15. Morse C.G., Mican J.M., Jones E.C., Joe G.O., Rick M.E., Formentini E., Kovacs J.A. The incidence and natural history of osteonecrosis in HIV-infected adults. Clin. Infect. Dis. 2007; 44: 739-748.
16. Lipman M., Breen R. Immune reconstitution inflammatory syndrome in HIV. Curr. Opin. Infect. Dis. 2006; 19:20-25.
17. Maganti R.M., Reveille J.D., Williams F.M. Therapy insight: the changing spectrum of rheumatic disease in HIV infection. Nat. Clin. Pract. Rheumatol. 2008; 4(8): 428-438.
18. Walker U.A., Tyndall A., Daikeler T. Rheumatic conditions in human immunodeficiency virus infection. Rheumatology. 2008; 47(7): 952-959.
19. Sellam J., Bouvard B., Masson C., Rousiere M., Villoutreix C., Lacombe K., Khanine V., Chennebault J.M., Leclech C., Audran M., Berenbaum F. Use of infliximab to treat psoriatic arthritis in HIV-positive patients. Joint Bone Spine. 2007; 74(2): 197-200.
20. Cepeda E.J., Williams F.M., Ishimori M.L., Weisman M.H., Reveille J.D. The use of anti-tumour necrosis factor therapy in HIV-positive individuals with rheumatic disease. Ann Rheum Dis. 2008;67(5):710-712.
21. Gaylis N. Infliximab in the treatment of an HIV positive patient with Reiter’s syndrome. J. Rheumatol. 2003; 30: 407-411.
22. Aboulafia D.M., Bundow D., Wilske K., Ochs U.I. Etanercept fort he treatment of human immunodeficiency virus-associated psoriatic arthritis. Mayo clinic. Proc. 2000; 75: 1093-1098.
23. Kaur P.P., Chan V.C., Berney S.N. Successful etanercept use in an HIV-positive patient with rheumatoid arthritis. J. Clin. Rheumatol. 2007; 13: 79-80.
24. Bartke U. Venten I., Kreuter A., ​​Gubbay S., Altmeyer P., Brockmeyer N.H. Human immunodeficiency virus-associated psoriasis and psoriatic arthritis treated with infliximab. Br. J. Dermatol. 2004; 150: 784-786.
25. Beltran B. Nos P., Bastida G., Iborra M., Hoyos M., Ponce J. Safe and effective application of anti-TNF-alpha in a patient infected with HIV and concomitant Crohn’s disease. Gut. 2006; 55: 1670-1671.