TNF-α inhibition in the setting of undiagnosed HIV infection: a call for enhanced screening guidelines

Abstract

Background: Despite the risks of immunosuppression, recommendations regarding screening for HIV infection prior to initiation of biologic therapies targeting common rheumatologic disorders, including inflammatory bowel disease (IBD) and inflammatory arthritides, are limited. Few cases of patients started on biologics while living with undiagnosed HIV infection have been reported. Methods:We report three cases of patients initiated on biologics in the absence of recent or concurrent HIV screening who developed refractory disease or unanticipated complications and were later found to have undiagnosed chronic HIV infection. Results:In Case 1, a 53-year-old MSM with negative HIV testing 2 years prior presented with presumed rheumatoid arthritis. He did not respond to methotrexate, so adalimumab was started. HIV testing to evaluate persistent symptoms was positive 9 months later; CD4 þ T-cell count was 800 cells/ml. Antiretroviral therapy (ART) resulted in resolution of symptoms, which were attributed to HIV-associated arthropathy. In Case 2, a 55-year-old woman with injection drug use in remission and no prior HIV testing presented with hidradenitis suppurativa. She started infliximab and methotrexate therapy with good response. After she developed weight loss and lymphopenia, an HIV test was positive; CD4 þ T-cell count was 334 cells/ml. Biologic hidradenitis suppurativa therapy was discontinued, with subsequent poor hidradenitis suppurativa control. In Case 3, a 32-year-old MSM with no prior HIV testing presented with presumed IBD; infliximab and steroids were started. Symptoms progressed despite IBD-directed therapy, and he was diagnosed with extensive Kaposi sarcoma with visceral and cutaneous involvement, likely exacerbated by immunosuppression. HIV testing was positive; CD4 þ T-cell count was 250 cells/ml. Kaposi sarcoma initially worsened due to ART-associated immune reconstitution inflammatory syndrome. He is now improving with systemic chemotherapy and ART. HIV-associated Kaposi sarcoma is presumed to be the underlying diagnosis. Conclusion:All three patients had elevated risk for HIV infection, and two had final diagnoses attributed to chronic HIV infection, not warranting therapeutic immunosupa

Hidradenitis Suppurativa in Patients with HIV: A Scoping Review

“…[ 52 , 54 ]. Therefore, close collaboration between oncological, dermatological, and infectious disease specialists is sometimes mandatory for a correct management of HS [ 29 , 31 ].…”

“…The complexity of the clinical and therapeutic management of HS is burdened by a high rate of clinical failures and recurrences; more so in people living with HIV [ 24 , 26 ]. Depending on the severity of the disease, its extension and patients’ comorbidities, HS treatment includes topical or systemic antibiotics (such as doxycycline, clindamycin, or erythromycin), corticosteroids, isotretinoin, antiandrogens and immunosuppressors [ 6 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 55 , 56 , 57 ]. Severe cases of HS may also require surgical removal of the lesions, thus causing difficult to accept cosmetic alterations [ 25 ].…”

“…Claytor et al decided to discontinue infliximab and methotrexate combination therapy in a 55-year-old woman with HS when an HIV test performed during the treatment came back positive. However, the immunosuppressive therapy has not been started again after she reached a good viral control and HS progressed aggressively [ 31 ].…”

Undiagnosed HIV in Patients on Immunosuppressive Medications Presenting with HIV-Associated Kidney Disease

“…These agents can place patients at increased risk of opportunistic infection and malignancy. 2,3 HIV directly or indirectly affects nearly all of the organ systems of the body, leading to a wide range of pathology, including HIV-associated renal diseases, enteropathies, and cancers, such as non-Hodgkin lymphoma (NHL). 4 Given this wide range of pathology and clinical manifestations, a missing HIV diagnosis may adversely affect disease management and prognosis when individuals with these conditions present for care.…”

“…One recent case series identified undiagnosed HIV + patients receiving biologic immunosuppression and developing unexpected opportunistic infections with worsened clinical presentation. 2 For some conditions, such as secondary glomerulonephritis, immunosuppression often is unnecessary, and treatment of the underlying disorder (eg, HIV) is the first-line therapy. Despite these risks, HIV testing before immunosuppression is not universal practice: Li et al found that among cancer survivors ages 65 years and younger in the United States, only 41% had ever received HIV testing.…”