Table 1. Musculoskeletal Manifestations in HIV Disease: Summary

Disorder Selected Features
Spondylarthropathies Reiter's syndrome Also termed "reactive arthritis." Classic presentation: large-joint arthritis, conjunctivitis, urethritis/cervicitis, oral ulcers, circinate balanitis, keratoderma blennorrhagica. Incomplete presentation more common in HIV; sometimes difficult to distinguish from nonspecific arthritis. Course usually self-limited, but treat severe disease. Use methotrexate with care -- can worsen immunodeficiency. Sulfasalazine may be helpful.
Psoriatic arthritis Sometimes difficult to distinguish from Reiter's syndrome. Oral gold therapy an alternative to methotrexate.
Acute symmetric polyarthritis Uncommon inflammatory arthritis of hands and small joints. Clinically similar to rheumatoid arthritis, with acute onset, morning stiffness, and indolent course, but patients are rheumatoid-factor-negative.
Painful articular syndrome Reported prevalence of up to 10% in selected populations with advanced HIV disease. Distinct from non-specific HIV-associated arthritis. Characterized by sterile inflammatory synovitis, with normal radiographic picture. Usually requires only pain control.
Septic arthritis Surprisingly low incidence in HIV population. Most cases associated with S. aureus and N. gonorrhoeae.
Myositis AZT myopathy Seen in up to 6% of patients on AZT for more than 6 months. May result from interaction between drug and mitochondrial DNA polymerase. Presents with proximal muscle weakness, myalgias, muscle wasting, and elevated creatine phosphokinase level. Usually reversible with cessation of drug; prednisone sometimes given adjunctively.
HIV-related polymyositis Clinical features similar to those of AZT myopathy -- progressive proximal muscle weakness and elevated creatine phosphokinase level. Histologic appearance is different: perivascular lymphocytic infiltrate.
Infectious myositis Three-phase illness presenting subacutely over 2 to 3 weeks; invasive phase, purulent phase, disseminated phase. Most present in second phase with leukocytosis and elevated sedimentation rate; creatine phosphokinase level often low and blood cultures rarely positive. Muscle abscess can be diagnosed with MRI (best), ultrasound, or CT. S. aureus responsible for most cases. Findings may be nonspecific.
Osteomyelitis Surprisingly uncommon in HIV population. Unusual pathogens and unusual routes of spread may be involved. Reported mortality very high -- about 20%. In early disease, S. aureus most common pathogen. Where endemic, skeletal tuberculosis seen. Radiographic studies are nonspecific. Findings can mimic those of skeletal KS.