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Year : 2013  |  Volume : 34  |  Issue : 2  |  Page : 107-112

Musculoskeletal and rheumatological disorders in HIV infection: Experience in a tertiary referral center

1 Department of Medicine, North Bengal Medical College, Darjeeling, India
2 Department of Medicine, Infectious Disease Hospital, Beliaghata, Kolkata, India
3 B P Poddar Hospital and Medical Research centre, New Alipore, Kolkata, West Bengal, India

Date of Web Publication25-Oct-2013

Correspondence Address:
Alakes Kumar Kole
Victoria Greens, Flat-A3/204, 385 Garia Main Road, Kolkata - 700 084, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0253-7184.120542

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Background: Musculoskeletal involvement in human immunodeficiency virus (HIV) infected patients are important disease manifestations, responsible for increased morbidity and also decreased quality of life. Objectives: To study the spectrum of different musculoskeletal involvement in HIV infected patients and its impact on quality of life. Patients and Methods: Three hundred (n = 300) HIV-1 reactive patients were evaluated in respect to different musculoskeletal involvement including the quality of life from January 2010 to January 2011. Results: Male to female ratio was 11:1 with a mean age of 35 (±6.4) years and mean duration of the disease was 3 (±1.54) years. Majority of cases were truck drivers, motel workers, and jewelry workers. Musculoskeletal disorders were observed in a total of 190 cases (63.33%). The spectrum of musculoskeletal involvement was: Body ache in 140 (46.7%), arthralgia in 80 (26.7%), mechanical low back pain in 25 (8.3%), osteoporosis in 20 (6.7%), painful articular syndrome in 10 (3.3%), hypertrophic osteoarthropathy in two (0.7%), pyomyositis in two (0.7%), osteomyelitis in one (0.3%), and avascular bone necrosis in one patient (0.3%). Rheumatologic disorders associated were: Reactive arthritis in seven (2.3%), fibromyalgia in four (1.3%), septic arthritis in three (1%), acute gout in three (1%), spondyloarthropathy in two (0.7%), rheumatoid arthritis in two (0.7%), dermatomyositis in one (0.3%), and systemic lupus erythematosus (SLE) in one patient (0.3%). But HIV associated arthritis and diffuse infiltrative lymphocytosis syndrome (DILS) were not detected. Most of the patients had decreased quality of life. Conclusions: Musculoskeletal involvement was common in HIV patients causing increased morbidity, so early detection and timely intervention is essential to improve quality of life.

Keywords: Human immunodeficiency virus infection, musculoskeletal disorder, quality of life

How to cite this article:
Kole AK, Roy R, Kole DC. Musculoskeletal and rheumatological disorders in HIV infection: Experience in a tertiary referral center. Indian J Sex Transm Dis 2013;34:107-12

How to cite this URL:
Kole AK, Roy R, Kole DC. Musculoskeletal and rheumatological disorders in HIV infection: Experience in a tertiary referral center. Indian J Sex Transm Dis [serial online] 2013 [cited 2023 Jan 27];34:107-12. Available from:

   Introduction Top

Human immunodeficiency virus (HIV) infection is pandemic nowadays and India harbors the second highest number of people with HIV/acquired immunodeficiency syndrome (AIDS) infection. [1] Besides the opportunistic infections, various musculoskeletal disorders in HIV infected patients are of great concern, not only for the treating physicians but also for the rheumatologists because of its diagnostic dilemma. With the introduction of highly active antiretroviral therapy (HAART) in 1995, life span of HIV patients had been prolonged, but there is subsequent emergence of various newer musculoskeletal disorders causing increased morbidity. The incidence of rheumatic manifestations in HIV infection was reported in about 4 to 71.3% cases in different studies depending on the stage of the disease/musculoskeletal involvements and was reported to be much more prevalent in HIV patients than the HIV negative population. [2],[3] Though musculoskeletal disorders are not always related to the HIV infection, these may be either the direct effect of the virus, opportunistic infections, noninfectious HIV complications (malignancy, drug toxicities), or unrelated rheumatologic disorders whose course have been altered by HIV infection on the immune system. [4],[5],[6] Musculoskeletal manifestations, though common in late stages, can occur at any stage, even may precede the diagnosis of HIV infection and many atypical manifestations may be present. Some of the risk factors (unsafe sexual practices and intravenous drug use) associated with HIV infection are shared with risk of developing certain rheumatic diseases. The spectrum of rheumatic manifestations in HIV infection include body ache, arthralgia, painful articular syndrome, reactive arthritis, HIV-associated arthritis, rheumatoid arthritis, undifferentiated spondyloarthropathy, systemic lupus erythematosus (SLE), fibromyalgia, septic arthritis, acute gout, avascular bone necrosis, osteoporosis, osteomyelitis, hypertrophic osteoarthropathy, polymyositis, dermatomyositis, pyomyositis, Sjogren's syndrome, diffuse infiltrative lymphocytosis syndrome (DILS), vasculitis, Kaposi's sarcoma, and lymphoma. But a great paradox in HIV infection is that certain rheumatic diseases such as DILS, reactive arthritis, Reiter's syndrome, and inflammatory myopathy are occurring in the face of immunodeficiency; whereas diseases like rheumatoid arthritis and SLE have been reported as improving in the face of the CD4 lymphocyte depletion. [7] Another important issue is difficulty in differentiating HIV infection from SLE which may also present with oral ulceration, alopecia, arthritis, fever, sicca syndrome, or neuropathy with false positive test for HIV antibody. [8] In the post HAART era, certain changes in musculoskeletal disorders were observed; decreasing prevalence of spondyloarthropathy and DILS and on other side increasing incidence of newer disorders such as osteopenia, osteonecrosis, and infective lesions. Moreover, with the immune restoration following HAART, certain inflammatory and autoimmune diseases (SLE, rheumatoid arthritis, and polymyositis) may exacerbate or even may develop de novo. [9] Musculoskeletal disorders in HIV infected patients greatly influence the quality of life in respect to physical, mental, social, and economic ground. [10] Early diagnosis and effective management, sometimes in consultation with a rheumatologist will reduce the morbidity and improve the overall quality of life.

The objectives of this study were to evaluate the different musculoskeletal involvement in HIV infected patients and its impact on quality of life.

   Patients and Methods Top

This was a cross-sectional observational study done in a tertiary referral hospital, Darjeeling, India from January 2010 to January 2011. A total of 300 HIV patients were enrolled for this study excluding recent history of trauma to joints, known diabetes or hypothyroidism, muscle weakness within 6 weeks of initiation of HAART therapy (probably zidovudine induced), and evaluated regarding the quality of life in respect to different musculoskeletal involvement (SF-36 questionnaire). Laboratory investigations including blood biochemistry, CD4 count, rheumatoid factor with titer, antinuclear antibody (ANA) with titer, anti-double stranded deoxyribonucleic acid (anti-dsDNA) antibodies, anti-neutrophil cytoplasmic antibodies (ANCAs), X-ray/ultrasonography/magnetic resonance imaging (MRI) of different joints, bone mineral density, electromyography- nerve conduction velocity (EMG-NCV) study, joint fluid analysis, and muscle biopsy were done.

   Results Top

Male to female ratio was 11:1 and the mean age was 35 (±6.4) years. Majority of them were truck drivers (70, 23.3%), motel workers (45, 15%), jewellery workers (40, 13.3%), prisoners (35, 11.7%), businessmen (30, 10%) [Table 1]. The major routes of transmission enquired were: Heterosexual practices in 220 (73.3%), intravenous drug use in 50 (16.7%), and blood/blood product transfusion in 15 (5%) [Table 2]. Mean duration of the disease observed was 3 (±1.54) years and mean CD4 count of 127 ± 28.3/mm 3 . A total of 238 patients were on HAART therapy currently, whereas 62 patients were not on HAART (among them 40 patients had never taken HAART and 22 patients stopped taking HAART). As per the World Health Organization (WHO) clinical staging, eight patients (2.7%) were in stage 1, 60 patients (20%) were in stage 2, whereas 160 patients (53.3%) were in stage 3 and 72 patients (24%) were in stage 4. Rheumatic manifestations in different combinations were observed in a total of 190 cases (63.33%) and the spectrum of involvement observed were body ache in 140 cases (46.7%), arthralgia in 80 (26.7%), mechanical low back pain in 25 (8.3%), osteoporosis in 20 (6.7%), osteoarthritis [Figure 1] in 18 (6%), painful articular syndrome in 10 (3.3%), hypertrophic osteoarthropathy in 2 (0.7%), pyomyositis in two (0.7%), osteomyelitis [Figure 2] in one (0.3%), and avascular necrosis of bone involving right femoral head in a patient (0.3%) on HAART who presented with severe pain in right hip region [Table 3]. The rheumatologic disorders associated were reactive arthritis [Figure 3] and [Figure 4] in seven cases (2.3%), fibromyalgia in four (1.3%), septic arthritis [Figure 5] in three (1%), acute gout in three (1%), spondyloarthropathy in two (0.7%), rheumatoid arthritis [Figure 6] and [Figure 7] in two (0.7%), and adhesive capsulitis [Figure 8] in one patient [Table 4]. Regarding the quality of life, HIV patients having musculoskeletal involvement had poor physical health in contrast to other HIV patients without musculoskeletal involvement (39.2 ± 4.3 vs 40.2 ± 4.7, P = 0.0153), whereas the mean mental health in both the above group were 38.1 ± 2.9 and 38.8 ± 3.3 (P = 0.0556), respectively. The laboratory investigation revealed positive rheumatoid factor in five patients, ANA in two patients and hepatitis B surface antigen in 10 patients. Synovial fluid aspiration was done in a total of eight patients, three of them revealed high leukocyte count (>50,000 cells/mm 3 ) suggestive of septic arthritis. Ultrasound and MRI of different joints done in a total of 15 patients and avascular necrosis of right femoral neck was detected in one patient.
Table 1: Occupations of human immunodeficiency virus patients

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Table 2: Different routes of transmission observed in this study

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Table 3: Spectrum of different musculoskeletal manifestations in respect to HAART therapy#

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Table 4: Spectrum of different rheumatological disorders in respect to HAART therapy

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Figure 1: Osteoarthritis with effusion involving left knee joint in a HIV patient

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Figure 2: Osteomyelitis in a HIV patient involving ankle joint

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Figure 3: Reactive arthritis in a human immunodeficiency virus patient involving left ankle, erythema nodosum involving both shin bone

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Figure 4: Reactive arthritis in a HIV patient with bilateral knee joint effusion

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Figure 5: Septic arthritis in a HIV patient involving left knee joint

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Figure 6: Rheumatoid arthritis with deformity in a HIV patient

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Figure 7: Rheumatoid arthritis without deformity in a HIV patient

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Figure 8: Adhesive capsulitis in a HIV patient involving right shoulder joint

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   Discussion Top

In this study, rheumatic manifestations were observed in a total of 63.33% of HIV patients corroborating with a study from Thailand (55%), whereas this was reported in only 31.5% in a study from Iran. [11],[12] The high prevalence of musculoskeletal involvement was probably due to a large number of number of HIV cases detected in advanced stages from different states of northeast India. Myalgia was the commonest symptom present in 46% patients and arthralgia involving knee, shoulder, and elbow were also frequent complaints and observed in about 26% of HIV patients requiring frequent analgesics for relief. The most distressing musculoskeletal disorders were mechanical low back pain and painful articular syndrome for which they required frequent outpatient visits and also frequent absence from their work. Reactive arthritis was detected only in 2.3% of HIV patients corroborating with other Indian studies and the mode of transmission was mainly heterosexual in contrast to western population where this was reported in 5-10% cases and mostly were homosexual. [13],[14],[15],[16],[17] Fibromyalgia was diagnosed in 1.3% of HIV patients in this study though this was the common musculoskeletal disorder reported from western population. [18] Septic arthritis involving the ankle and knee joints were observed in 1% of HIV patients and most of them were intravenous drug users. Spondyloarthropathy was seen in 0.7% of cases in this study corroborating with other Indian studies and also a study from China; and all these patients required biologics (infliximab) to control the disease activity and was significantly observed in patients without HAART (P = 0.004) [Table 5]. [13],[14] SLE was diagnosed in one female HIV patient who had a low CD4 count (112/mm 3 ) but developed flare (increased disease activity) after initiation of HAART. DILS, specific for HIV infection, was reported with a high percentage (11.22%) in a study from China, but not detected in this study as well as other Indian studies. [19] It had been observed that HIV patients of stage 2 had suffered predominantly from arthralgia, spondyloarthropathy, and rheumatoid arthritis; whereas patients with stage 3 disease had suffered predominantly from body ache and mechanical low back pain, but patients with stage 4 disease had suffered predominantly from septic arthritis, osteomyelitis, and pyomyositis [Table 6]. Another important observation was that patients on prolonged HAART therapy developed osteoporosis (6.7%) and osteonecrosis (0.3%), possibly due to the metabolic effects of the antiretroviral drugs though there is no controlled study to prove this association [Table 3]. [20] Most of the patients in this study had history of frequent outpatient visit or hospital admission due to incapacitating pain due to musculoskeletal disorders in addition to opportunistic infections hampering their day-to-day activities, resulting in long absence from work. Moreover, it had been observed that majority of the HIV patients in this study were from lower socioeconomic group and were also the earning members of their families, resulting in economic crisis.
Table 5: Spectrum of different rheumatologic disorders in HIV patients and comparison to other Indian studies (% of cases)

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Table 6: Musculoskeletal involvement in different stages of HIV infection

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The major challenges for a physician practicing in HIV endemic area include not only recognizing HIV infection associated rheumatic disorders but also distinguishing them from classic rheumatic diseases like rheumatoid arthritis, SLE, spondyloarthropathy, and vasculitis. So an aggressive multidisciplinary approach to early detection and timely intervention of these disorders, sometimes in consultation with a rheumatologist are all essential for effective management and to improve the quality of life. Moreover a well-balanced diet and exercise program in addition to HAART therapy may be the best way to maintain good health in these groups of patients.

   References Top

1.UNAIDS: Fact sheet; AIDS Epidemic in Asia; 2004.  Back to cited text no. 1
2.Calabrese LH. Human immunodeficiency virus (HIV) infection and arthritis. Rheum Dis Clin North Am 1993;19:477-88.  Back to cited text no. 2
3.Medina-Rodriguez F, Guzman C, Jara LJ, Hermida C, Alboukrek D, Cervera H, et al. Rheumatic manifestations in human immunodeficiency virus positive and negative individuals: A study of 2 populations with similar risk factors. J Rheumatol 1993;20:1880-4.  Back to cited text no. 3
4.Berman A, Espinoza LR, Diaz JD, Aguilar JL, Rolando T, Vasey FB, et al. Rheumatic manifestation of human immunodeficiency virus infection. Am J Med 1988;85:59-64.  Back to cited text no. 4
5.Rodriguez W. Musculoskeletal manifestations of HIV disease. J Watch HIV/AIDS Clin Care 1998.  Back to cited text no. 5
6.Musculoskeletal Disorders Are Often Associated With HIV Infection From U.S. Centers for Disease Control and Prevention; 2002.  Back to cited text no. 6
7.Reveille JD. Rheumatic manifestations of human immunodeficiency virus infection. In: Harris ED, Budd RC, Genovese MC, et al. editors. Kelley's Textbook of Rheumatology. 7 th ed. USA: Elsevier Saunders; 2005. p. 1661-75.  Back to cited text no. 7
8.Diri E, Lipsky PE, Berggren RE. Emergence of systemic lupus erythematosus after initiation of highly active antiretroviral therapy for human immunodeficiency virus infection. J Rheumatol 2000;27:2711-4.  Back to cited text no. 8
9.Nguyen BY, Reveille JD. Rheumatic manifestations associated with HIV in the highly active antiretroviral therapy era. Curr Opin Rheumatol 2009;21:404-10.  Back to cited text no. 9
10.Hudson A, Kirksey K, Holzemer W. The influence of symptoms on quality of life among HIV-infected women. West J Nurs Res 2004;26:9-23.  Back to cited text no. 10
11.Chiowchanwisawakit P, Koolvisoot A, Ratanasuwan W, Suwanagool S. Prevalence of rheumatic disease in HIV infected Thai patients. J Med Assoc Thai 2005;88:1775-81.  Back to cited text no. 11
12.Azami A, Paydary K, Seyedian SL, Koochak HE, Khalvat A, Najafizade SR, et al. Rheumatologic manifestations among HIV-positive patients, Tehran, Iran. Thrita J Med Sci 2012;1:145-8.  Back to cited text no. 12
13.Narayanan K, Batra RB, Anand KP. Rheumatic manifestations of HIV infection. Indian J Rheumatol 2008;3:4-7.  Back to cited text no. 13
14.Achuthan K, Uppal SS. Rheumatological manifestations in 102 cases of HIV infection. JIRA 1996;3:43-7.  Back to cited text no. 14
15.Kutty Krishnan K, Panchapakesa RC, Porkodi R, Madhavan R, Ledge SG, Mahesh A. Rheumatological manifestations in HIV positive patients referred to a tertiary care centre. J Indian Rheumatol Assoc 2003;11:104-8.  Back to cited text no. 15
16.Forster SM, Seifert MH, Keat AC, Rowe IF, Thomas BJ, Taylor-Robinson D, et al. Inflammatory joint disease and human immunodeficiency virus infection. Br Med J (Clin Res Ed) 1988;296:1625-7.  Back to cited text no. 16
17.Winchester R. AIDS and the Rheumatic disease. Bull Rheum Dis 1990;39:1-10.  Back to cited text no. 17
18.Simms RW, Zerbini CA, Ferrante N, Anthony J, Felson DT, Craven DE. Fibromyalgia syndrome in patients infected with human immunodeficiency virus. The Boston City Hospital Clinical AIDS Team. Am J Med 1992;92:368-74.  Back to cited text no. 18
19.Zhang X, Li H, Li T, Zhang F, Han Y. Distinctive rheumatic manifestations in 98 patients with human immunodeficiency virus infection in China. J Rheumatol 2007;34:1760-4.  Back to cited text no. 19
20.Maganti RM, Reveille JD, Williams FM. Therapy insight: The changing spectrum of rheumatic disease in HIV infection. Nat Clin Pract Rheumatol 2008;4:428-38.  Back to cited text no. 20


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]

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