Refractory Polyarticular Gouty Arthritis as a Manifestation of Immune Reconstitution Inflammatory Syndrome

Abstract

Immune reconstitution inflammatory syndrome (IRIS) describes the initial clinical deterioration some patients manifest upon initiation of effective antiretroviral therapy (ART) for HIV infection. In this report we describe a case of IRIS manifesting as polyarticular gout, a previously unreported rheumatological manifestation of IRIS. A 53-year-old HIV-infected man with a history of intermittent attacks of gout and an initial CD4 count of 112 cells/microL and a viral load of >100,000 copies/mL presented to our institution with severe, refractory, polyarticular gout approximately 4 weeks after initiating ART. At this point, the patient demonstrated significant gains in his CD4 counts (103 cells/microL) and a greater than 3 log decline in his HIV-1- viral load. This episode was prolonged lasting for approximately 10 weeks and required hospitalization for the management of pain and control of inflammation. The temporal associations of this attack with the initiation of ART and the observed immunologic reconstitution make IRIS a clinical possibility.Monosodium urate crystals through their interactions with interleukin 1- beta, and neutrophilic synovitis play a critical role in the pathophysiology of gout. Defects in both neutrophil and macrophage function and imbalances in the cytokine milieu are documented in HIV infected patients. The introduction of ART results in restoration of neutrophil and macrophage function, declines in levels of the anti-inflammatory cytokine IL-10, and increases in levels of proinflammatory cytokines including IL-1 beta, which may provide the necessary milieu for the precipitation of attacks of severe polyarticular gout in the context of ART initiation.

Acute gouty arthritis as a manifestation of immune reconstitution inflammatory syndrome after initiation of antiretroviral therapy

“…The present case shares resemblance to the previously reported patient who presented with polyarticular gouty arthritis as a manifestation of IRIS 9 . In contrast to the case reported by SEBENY et al 9 , our patient had no prior history of gout and presented with monoarticular disease.…”

“…The present case shares resemblance to the previously reported patient who presented with polyarticular gouty arthritis as a manifestation of IRIS 9 . In contrast to the case reported by SEBENY et al 9 , our patient had no prior history of gout and presented with monoarticular disease. Interestingly, he presented a relentless acute gout syndrome associated with exquisite pain that lasted three months and went on to develop signs of a draining tophus, which is uncommon in patients without prior signs and symptoms of gout.…”

“…Since then, a variety of non-infectious IRIS cases have been reported, including sarcoidosis 7 , lymphoid pneumonitis 7 , cutaneous reaction to tattoo pigment 11 , alopecia universalis and Graves disease 10 , rheumatoid arthritis 2 , and Guillain-Barré syndrome 8 . SEBENY et al 9 have previously reported on a 53-year-old HIV-infected male patient with a history of intermittent attacks of gout who developed severe polyarticular gouty arthritis one week after initiation of a HAART regimen consisting of tenofovir, emtricitabine and efavirenz.…”

Peripheral Neurokinin-1 Receptors Contribute to Kaolin-Induced Acute Monoarthritis in Rats

“…PMN cells are known to play a deleterious role in the acute phase of arthritic conditions such as RA and refractory gout [27,28]. Once in the joint, they produce reactive oxygen species and cytokines, thus contributing to an ongoing state of inflammation in the joint and joint destruction [29,30,31,32].…”

Prevalence of and risk factors for gout in HIV-positive adults: A case–control study

“…5 In addition, there have been a number of case reports published. [6][7][8][9][10][11] Observational studies that have estimated the prevalence of gout in their HIV-positive patients have reported rates ranging between 0.4% in Nigeria 12 and 1% among patients attending a tertiary referral centre in India. 13 One UK study investigating the risk of infectious diseases among people with gout found that 0.1% of people with gout in the Clinical Practice Research Datalink (a large representative primary care database) had co-existent HIV.…”