Enthesitis and Enthesopathy

Enthesopathy, Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome (AIDS)

HIV related Enthesitis

Patients who are HIV positive can get joint pains and arthritis for a number of reasons.

These reasons include join pain from non-HIV related problems such as injury or tendonitis or as a side effect of some of the medications used to treat AIDS.

This page deals with a specific type of joint problem that is called enthesitis or inflammation at insertion of tendons or ligaments to bone. If you think you suffer from this problem then you should see your primary care doctor or physician.

Prior to effective therapy for AIDS inflammatory problems at insertion sites were very common and manifested with Achilles enthesitis, other isolated enthesopathies, joint swelling or spinal disease.

The advent of highly active anti-retroviral therapy (HAART) by treating the underlying immunodeficiency state had a dramatic effect on the enthesitis related arthritis seen in HIV with its virtual disappearance where therapy is available.

However, enthesitis may still occur in HIV setting especially as a complication of genitourinary or gastrointestinal infectious with different microbes including Chlamydia, salmonella, shigella and others being implicated.

This is termed reactive arthritis. Enthesitis related arthritis including reactive arthritis is classified as a form of Spondyloarthropathy.

Immune Mechanism of HIV related Arthritis

The two major categories of inflammatory arthritis are rheumatoid arthritis and Spondyloarthropathy.

Before the age of effective therapies for HIV it was noted that rheumatoid arthritis tended to improve with advanced AIDS but spondyloarthorpathy tended to occur or get worse.

Simplistically put this is thought to be due to:

  • the presence of microbes or their cellular constituents being more abundant in AIDS
  • the relative preservation of CD8 T lymphocytes in AIDS
  • the localisation of AIDS related to entheses that are sites of high mechanical stress

This is illustrated in the table below:

Rheumatoid arthritis Spondylarthropathy
MHC association - HLA-DR4 CD4 T-cells which contribute to inflammation are depleted in advanced HIV. MHC association - HLA-B27 CD8 T-cells also diminish but are spared compared to CD4 cells.
Primary target tissue - the synovial membrane. Primary target tissue - sites of increased biomechanical stress in the joints, especially the enthesis, adjacent marrow, capsules/
Triggers - unknown. Rheumatoid factors? Infection? Triggers - bacteria/virus (including HIV). Genitourinary and bowel inflammation maybe commoner in homosexuals, thus allowing greater access of bacteria to the circulation.
McGonagle D, Reade S, Marzo-Ortega H, Gibbon W, O'Connor P, Morgan A, Melsom R, Morgan E, Emery P. Human immunodeficiency virus associated spondyloarthropathy: pathogenic insights based on imaging findings and response to highly active antiretroviral treatment. Ann Rheum Dis. 2001 Jul;60(7):696-8

The different aspects of enthesopathy and enthesitis can be found on this site