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Patient Case: HIV-Associated Rheumatic Syndrome

Patient Case: HIV-Associated Rheumatic Syndrome

Discussion

A 40-year-old male presents to a regional hospital with a two-month history of joint pain and swelling, mainly affecting his knees, ankles, and wrists. He describes stiffness in the morning that lasts for over an hour. He also reports fatigue, weight loss, and intermittent low-grade fevers.

His past medical history includes a diagnosis of HIV two years ago, but he has been inconsistent with his antiretroviral therapy (ART). On examination, multiple joints are warm and tender, with mild effusions. No deformities are noted. Skin examination reveals hyperpigmented macules on his legs, and he has mild oral thrush.

Laboratory tests show a low CD4 count, elevated inflammatory markers (ESR and CRP), and negative rheumatoid factor and anti-CCP antibodies. Joint aspiration reveals a mild inflammatory fluid without infection. A diagnosis of HIV-associated rheumatic syndrome is made. The patient is counseled on ART adherence and started on nonsteroidal anti-inflammatory drugs (NSAIDs) and physiotherapy for symptom relief.

Questions
1. What is the most likely diagnosis in this patient?

a) Rheumatoid arthritis

b) HIV-associated rheumatic syndrome

c) Gout

d) Osteoarthritis

2. Which of the following findings supports the diagnosis of HIV-associated rheumatic syndrome rather than rheumatoid arthritis?

a) Positive anti-CCP antibodies

b) Symmetric joint involvement with joint erosions

c) Negative rheumatoid factor and anti-CCP with a history of untreated HIV

d) Presence of tophi around the joints

3. What is the most important aspect of management for this patient?

a) Disease-modifying anti-rheumatic drugs (DMARDs)

b) Strict adherence to antiretroviral therapy (ART)

c) High-dose corticosteroids

d) Long-term opioid therapy

4. Which of the following complications is most concerning in untreated HIV-associated rheumatic syndrome?

a) Progressive joint deformities

b) Increased risk of opportunistic infections and systemic inflammation

c) Development of uric acid crystal deposits

d) Permanent bone erosion visible on X-ray

Reveal answers

Answers

1. b) HIV-associated rheumatic syndrome

The patient has chronic joint pain with a history of untreated HIV, negative rheumatoid markers, and systemic symptoms like weight loss and oral thrush, making HIV-associated rheumatic syndrome the most likely diagnosis.

2. c) Negative rheumatoid factor and anti-CCP with a history of untreated HIV

Unlike rheumatoid arthritis, which is associated with positive anti-CCP and joint erosions, HIV-related arthritis is typically seronegative and improves with ART.

3. b) Strict adherence to antiretroviral therapy (ART)

The most critical aspect of treatment is controlling HIV itself. ART helps reduce immune activation, which can improve joint symptoms. NSAIDs may be used for symptom relief.

4. b) Increased risk of opportunistic infections and systemic inflammation

If untreated, HIV-associated rheumatic syndrome can lead to worsening immunosuppression, increasing the risk of infections, systemic inflammation, and complications such as reactive arthritis or vasculitis.