1. Definition and differentiation. These syndromes are unique to HIV-infected persons. They are among the most common musculoskeletal manifestations but because of the paucity of anatomic findings are the most difficult to delineate. It is convenient to distinguish them arbitrarily from HIV-associated arthropathy by the absence of joint effusions. The clinical presentations require differentiation from enthesopathy, periostitis, myositis, and neuropathy, although these may coexist. One may discern two types on clinical grounds:
a. Acute. The acute painful articular syndrome is dramatic. Typically, the patient is carried by friends into the emergency department and complains of the rapid onset of pain in the knees or ankles. It is frequently symmetric. The physical findings are unimpressive except that the patient may not be able to stand. Response to NSAIDs is poor. Often, narcotics are required for pain control. The symptoms abate within 2 to 24 hours, although they may last for a few days. The recovery is with minimal residuum.
b. Subacute. Typically, this syndrome has a gradual onset during a period of a few weeks. It too has a predilection for knees and ankles. At times, it appears as a classic patellofemoral syndrome and may be accompanied by some degree of quadriceps femoris atrophy. Often, direct palpation in the area of complaint will elicit diffuse tenderness of muscle, tendons, and bone, suggesting myositis, enthesitis, or periostitis. Most cases gradually resolve during weeks or months and require minimal intervention. Some are progressive and lead to significant debility.
2. Pathology. Little is known about the etiology of these syndromes, but recurrent ischemia may be an underlying factor. This is supported by the following evidence:
a. The acute form is most reminiscent of the musculoskeletal pain of a sickle cell crisis in its rapidity of onset and resolution, and in the poor correlation between the severity of complaints and the physical findings.
b. Necropsy specimens of knee synovium show effacement consistent with recurrent ischemic insult.
c. Some have suggested a predilection toward osteonecrosis in HIV-infected patients. Although no studies have been performed to support this claim, anecdotes of extensive aseptic necrosis in persons without other known predisposing factors tend to support this possibility.
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