Tenosynovitis as a possible feature of immune reconstitution syndrome during highly active antiretroviral treatment (HAART)

doi:10.1016/j.jbspin.2009.01.008

Joint Bone Spine

Volume 76, Issue 5, October 2009, Pages 550-552

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Abstract

An immune reconstitution syndrome (IRS) occurs in between 10% and 25% of patients starting highly active antiretroviral treatment (HAART). A 49-year-old patient presents a tenosynovitis 6 weeks after HAART initiation. In our patient, exhaustive tests for infectious, inflammatory and drug-related causes of tenosynovitis were negative. The improvement obtained with high-dose Non-steroidal anti-inflammatory-drug (NSAID) therapy and the patient's immunovirologic profile, supported a diagnosis of tenosynovitis associated with immune reconstitution, a form of IRS that has not previously been described. This original case increase the broad spectrum of inflammatory rheumatologic disorders associated with HIV infection.

Introduction

An immune reconstitution syndrome (IRS) occurs in between 10% and 25% of patients starting highly active antiretroviral treatment (HAART) [1]. It appears to be due to the reconstitution of specific immunity to certain antigens, both microbial and non microbial, in patients with immunological and/or genetic risk factors [2]. This syndrome was first described with opportunistic pathogens such as cytomegalovirus, Cryptococcus neoformans and other bacteria [3]. Immunoinflammatory and rheumatic manifestations have also been reported, including sarcoidosis and thyroid disorders (Hashimoto and Basedow's disease), aseptic inflammatory arthritis and lupus-like connective tissue inflammation [3], [4], [5]. Malignant and septic arthritis (lymphoma, Kaposi's sarcoma) now represent more than 50% of the rheumatologic disorders observed in HIV-infected patients since the advent of HAART [6]. However, peripheral inflammatory disorders such as tenosynovitis have not yet been reported in this setting. Here, we describe a case that adds to the already broad spectrum of inflammatory rheumatologic disorders associated with HIV infection.

Section snippets

Case report

A 49-year-old Cameroonian man was diagnosed with HIV-1 infection in August 2006, after developing persistent diarrhea along with an altered general state. We noticed former attacks of gout. His CD4+ cell count was 53/mm³ (10%), the CD8+ cell count was 345/mm³ (65%), the CD4/CD8 ratio was 0.2 and the viral load was 800 000 copies/mm³ (5.83 log₁₀). Treatment with lamivudine, tenofovir, fosamprenavir and ritonavir was started in late August 2006. Six weeks later he presented with a painful and swollen

Discussion

This patient's history, clinical manifestations and biological findings were suggestive of aseptic arthritis and bilateral tenosynovitis associated with an IRS. Based on previously described criteria [1], the main supporting arguments were the following: the chronology (onset 6 weeks after starting boosted protease inhibitor therapy), the patient's young age, the profound immunodepression at the outset of antiretroviral treatment, the rapid decline in viral load (reduction of 2.7 log₁₀ in a

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Drug-induced tendon toxicity is rare but often underestimated. To date, four main drug classes have been incriminated in tendinopathies. Quinolones and long-term glucocorticoids are the most widely known, but statins and aromatase inhibitors can also induce tendon damage. The specific pathophysiological mechanisms responsible for drug-induced tendinopathies remain unknown. Proven risk factors have been identified, such as age older than 60 years, pre-existing tendinopathy, and potentiation of toxic effects when several drug classes are used in combination. Mean time to symptom onset varies from a few days with quinolones to several months with statins and several years for long-term glucocorticoid therapy. The most common sites of involvement are the lower limb tendons, most notably the body of the Achilles tendon. The first part of this review discusses tendon anatomy and the pathophysiology and radiological manifestations of tendinopathies. The second part provides details on the main characteristics of each of the drugs classes associated with tendon toxicity.
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Case reportTenosynovitis as a possible feature of immune reconstitution syndrome during highly active antiretroviral treatment (HAART)

Abstract

Introduction

Section snippets

Case report

Discussion

Semin Arthritis Rheum

Rheum Dis Clin North Am

Incidence and risk factors for immune reconstitution inflammatory syndrome in an ethnically diverse HIV type 1-infected cohort

Clin Infect Dis

Immune restoration disease after antiretroviral therapy

AIDS

Inflammatory reactions in HIV-1-infected persons after initiation of highly active antiretroviral therapy

Ann Intern Med

Immune reconstitution inflammatory syndrome in HIV-infected patients receiving antiretroviral therapy: pathogenesis, clinical manifestations and management

Drugs

Case report
Tenosynovitis as a possible feature of immune reconstitution syndrome during highly active antiretroviral treatment (HAART)