Rheumatologic complications of HIV infection

Acute HIV infection, also called the acute retroviral syndrome, is the symptomatic viremic phase in the days to weeks after HIV acquisition, presenting with fever, fatigue, myalgia, rash, and pharyngitis at a time when antibody testing may still be negative. Diagnosis requires an HIV RNA viral load, and antiretroviral therapy should begin as soon as the patient is ready, regardless of CD4 count.

Antiretroviral therapy (ART) combines three or more drugs from at least two classes to suppress HIV replication. First-line therapy is bictegravir/emtricitabine/tenofovir alafenamide or dolutegravir-based triple therapy, started as soon as the patient is ready regardless of CD4 count, and continued for life to prevent AIDS and transmission.

Reactive arthritis is a sterile, human leukocyte antigen B27 (HLA-B27)-associated spondyloarthritis that follows a genitourinary or enteric infection by 1 to 4 weeks, producing asymmetric lower-limb oligoarthritis, enthesitis, and the urethritis-conjunctivitis-arthritis triad. It is a clinical diagnosis of a culture-negative joint. First-line treatment is an NSAID such as piroxicam for at least 2 weeks, escalating to glucocorticoids and then sulfasalazine or a tumor necrosis factor (TNF) inhibitor for disease persisting beyond 3 to 6 months.

Psoriatic arthritis (PsA) is a seronegative spondyloarthritis that develops in up to 30% of patients with psoriasis, producing asymmetric oligoarthritis or distal interphalangeal joint disease, dactylitis, enthesitis, nail dystrophy, and axial involvement. Diagnosis is clinical, supported by the CASPAR criteria. Limited peripheral disease is treated with an NSAID or intra-articular glucocorticoid, more active disease with methotrexate, a tumor necrosis factor inhibitor, or an interleukin-17 inhibitor.

Sjogren syndrome is a systemic autoimmune exocrinopathy in which lymphocytic infiltration of the lacrimal and salivary glands causes keratoconjunctivitis sicca and xerostomia, occurring alone (primary) or alongside another rheumatologic disease such as rheumatoid arthritis or lupus (secondary). Diagnosis combines the anti-Ro (SSA) and anti-La (SSB) antibody panel, objective dryness testing, and labial salivary gland biopsy under the 2016 ACR/EULAR classification criteria. Management centers on sicca-directed therapy, pilocarpine or cevimeline for xerostomia and topical cyclosporine for keratoconjunctivitis, with hydroxychloroquine or immunosuppression for extraglandular disease.

Avascular necrosis (osteonecrosis) is ischemic bone death, most commonly of the femoral head, driven chiefly by glucocorticoid use and alcohol overuse; management pivots entirely on whether subchondral collapse has occurred, since joint-preserving surgery works only before collapse and total joint arthroplasty is required after it.

Vasculitis is inflammation and necrosis of blood vessel walls, classified by the Chapel Hill scheme into large, medium, small (ANCA-associated versus immune-complex), and variable-vessel disease, each with a vessel-size-predicted clinical syndrome. Diagnosis requires excluding mimics such as infective endocarditis and cholesterol embolization before confirming with serology and biopsy, and treatment is glucocorticoid induction plus cyclophosphamide or rituximab for organ-threatening disease.

HIV infection produces cytopenias, coagulation abnormalities, and B-cell lymphomas through mechanisms that shift with CD4 count, from immune-mediated peripheral destruction and drug toxicity at higher CD4 counts to opportunistic marrow infiltration and aggressive lymphoma once CD4 falls below 100-50/mcL. Antiretroviral therapy is the single most effective intervention across nearly all of these complications, and management otherwise follows the specific cytopenia or malignancy identified after excluding drug causes, nutritional deficiency, and coinfection.