AIDS AND REACTIVE ARTHRITIS.
An aggressive form of Reiter's syndrome may develop in patients with AIDS (seeChapter 417). Early reports suggested that Reiter's syndrome developed in many HIV-infected individuals after profound immunosuppression. Although it has been suggested that AIDS patients are at increased risk of reactive arthritis, a number of prospective analyses of HIV-infected populations failed to reveal an increased incidence or prevalence of Reiter's syndrome when compared with that observed in an HIV-negative population matched for other risk factors. It seems clear that HIV infection alters the clinical expression of Reiter's syndrome. The vast majority of AIDS patients with Reiter's syndrome are HLA-B27+ and have incomplete symptoms and signs of Reiter's syndrome. The arthritis evolves in two main patterns: (1) an additive, asymmetrical polyarthritis or (2) an intermittent oligoarthritis that most commonly affects the lower extremities. Enthesitis, fasciitis, conjunctivitis, and urethritis are early and prominent symptoms. Although sacroiliitis does occur, HIV-associated reactive arthritis is rarely associated with axial disease or uveitis. HIV-associated disease also differs from classic Reiter's syndrome in the severity and chronicity of disease, prominent enthesitis, and a poor response to non-steroidal anti-inflammatory drugs (NSAIDs).
PSORIATIC ARTHRITIS.
Psoriatic arthritis develops in 5 to 7% of patients with cutaneous psoriasis. Although most cases arise in patients with established, active cutaneous disease, other patients (especially children) have articular disease that antedates the development of psoriasis. Although the extent of psoriatic skin disease correlates poorly with the onset of arthritis, the risk of psoriatic arthritis increases with a family history of spondyloarthropathy or extensive nail pitting. The age of onset is usually between 30 and 55 years, and psoriatic arthritis has been shown to affect men and women equally. Psoriatic spondylitis, however, has a male-female ratio of 2.3:1.
