How does reactive arthritis typically present in an HIV patient?
The incidence of ReA associated with HIV infection is 0.5% to 3% but has declined significantly since ART was introduced. The onset may precede the diagnosis of acquired immunodeficiency (AIDS) by up to 2 years, occur concomitantly, or most commonly present in the setting of severe established immunodeficiency. A seronegative oligoarthritis of the lower extremities and urethritis are common, but conjunctivitis is rare. Enthesopathy, plantar fasciitis, dactylitis, stomatitis, and skin and nail changes are common, and balanitis may be seen. Axial skeletal involvement and uveitis are unusual. Synovial fluid is inflammatory (2000–10,000 cells/μL), and cultures are negative. The clinical course is typically one of mild arthritis with remissions and recurrences. Severe erosive arthritis does occur and can be very debilitating. The frequency of HLA-B27 in HIV-positive ReA patients is the same as that found in HIV-negative ReA patients of the same race. ReA rates tend to be higher in areas where HIV is primarily transmitted by sexual encounters rather than by intravenous drug use (Central and South America and Africa). However, in Asian cohorts, there are few cases of ReA reported despite the majority HIV cases being transmitted sexually. Early ART introduction and/or changes in sexual practices may account for lower ReA rates in the United States.
