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Musculoskeletal manifestations in pediatric patients infected with human immunodeficiency virus: Developing country perspective.

Introduction

Human immunodeficiency virus (HIV) infection is prevalent worldwide, with India harboring the third largest number of people with HIV/acquired immunodeficiency syndrome (AIDS) infection, 3% of whom are children (1). Worldwide, the total number of children infected with HIV has been estimated at 3.2 million, majority of whom are living in sub-Saharan Africa (2). Children living with HIV/AIDS (CLHIV) form a vulnerable subsection, and may frequently present with clinical symptoms in the first year of life itself. Irrespective of CD4 status, any child aged below 5 years infected with HIV should be started on highly active anti-retroviral therapy (HAART) at the earliest to avoid severe damage to his/her immature immune system.

Musculoskeletal manifestations comprise an immensely important but often neglected group of co-morbidities among CLHIV. The early symptoms of musculoskeletal manifestations as well as the progression of the ailments are often neglected by the patients not only due to the simultaneous presence of the primary disease and/other life-threatening co-morbidities but also due to their overall lower quality of life. Majority of the studies on rheumatological manifestations in patients with HIV have been done in adults (3-9). A few studies have reported rheumatological problems in pediatric patients with HIV, mostly from North America and Africa (10-15), but to the best of our knowledge, no large-scale prospective study is available from the Asian subcontinent. Involvement of other systems like neurological (16, 17), gastrointestinal (18), and hematological (19) have been extensively studied in pediatric patients, but there are few studies concerning the musculoskeletal feature among patients with HIV. This study aimed to explore the prevalence and clinical correlates of musculoskeletal manifestations in CLHIV.

Methods

A single-center, prospective, observational study was carried out from October 2014 to September 2016 in the Regional Pediatric Anti-Retroviral Therapy (ART) Centre of a tertiary care hospital in Eastern India. The treatment and management of primary disease (HIV/AIDS) of these children were done by the State ART Centre according to WHO/NACO protocol. Children aged between 3 and 19 years, diagnosed as a case of HIV infection by Enzyme Linked immunosorbent assay (ELISA) test and/or DNA Polymerase Chain Reaction (PCR), were included with purposive sampling. Informed consent/assent (as applicable) was taken before recruitment, and the study protocol was approved by the Institutional Ethics Committee for Human Research. Children who were having musculoskeletal manifestations due to co-morbid conditions like fracture or surgery were excluded. All the children were followed up for six months.

Data regarding disease history, present status of HIV infection, medication, and co-morbid illnesses were recorded in pre-designed proforma. Details of musculoskeletal involvement were noted. Malnutrition in these children was determined by body mass index (B.M.I.) in case of children aged >5 years, and by weight for age in case of children aged [less than or equal to]5 years. A rapid screening of the musculoskeletal system was performed with the help of pediatric gait, arm, leg, spine (pGALS) screening protocol (20). At first, the study participants were shown videos of the movement that they needed to do for screening, and subseguentlythey were asked to imitate those movements. Following the screening examination, a more detailed examination of the relevant area, based on the "look, feel, move" principle as in the Regional Examination of the Musculoskeletal System (called REMS) was done. If any abnormality was suspected in a particular or group of joints or muscle, they were examined by X-ray, ultrasonography, relevant blood tests (complete blood count, erythrocyte sedimentation rate-ESR, C reactive protein-CRP, creatine kinase, liver function test), and serological investigations (antinuclear antibody-ANA, rheumatoid factor-RA factor). All the participants were re-examined at three- and six-month intervals. Repeat CD4 count was checked after six months. On every visit, each patient was evaluated for relevant signs and symptoms, and for growth and development monitoring.

Data were recorded on a pre-designed proforma, and were entered in Microsoft Excel 2007 spreadsheets and analyzed using IBM[R] SPSS[R] Statistics Version 22.0 (IBM Corp.; Armonk, NY, USA). p<0.05 was considered significant.

Out of 579 children infected with HIV, parents of 562 children (97.06%) consented for inclusion in our study. Eleven children died. Thirty-four children were lost to follow-up. A total of 517 children (89.29%) who had regular follow-up were included in the study (Figure 1). Baker-Wong Faces Pain Rating Scale and Visual Analogue Scale (21) were used to scale musculoskeletal pain in the age groups 3-8 years and 9-19 years, respectively. "Significant pain" was defined as >5 scoring in pain scale appropriate for that age group, and/requiring medication for relief from pain on a regular basis.

Result

A total of 517 pediatric patients of age 3-19 years were included in the final analysis of this study. Amongst them, 59.9% belonged to the age group 9-19 years. Approximately 13.5% of the study population were aged 9 years (highest). A total of 51.8% of the evaluated children were males. Children evaluated were diagnosed at 1-16 years with a mean ([+ or -]SD) age of diagnosis 4.317 ([+ or -]2.774) years, and the duration of disease in these children were from 1 to 17.5 years with a mean ([+ or -]SD) duration of 7.301 ([+ or -]3.004) years (Table 1). A total of 20.9% of study population were affected by malnutrition.

The mean ([+ or -]SD) CD4 count at diagnosis was 786.02 ([+ or -]251.080) cells/[micro]L, while the mean ([+ or -]SD) CD4 count at the time of evaluation was 516.81 ([+ or -]255.955) cells/[micro]L. The distribution of CD4 count at the time of evaluation with respect to musculoskeletal manifestation is depicted in Figure 2. In the study population, 37.7% (highest among all groups) belonged to Stage 3 of W.H.O Clinical staging system of HIV/AIDS. During assessment, around three-fourths (76.98%) of the study population was on HAART medication. Musculoskeletal manifestations were found in 11.2% children (different manifestations are depicted in Figure 3), frequent in the age group of 9-19 years (p=0.046-Fisher's exact test) with no significant gender predilection. A lower CD4 cell count at the time of evaluation was significantly (p=0.008-Independent Mann-Whitney U Test) associated with presence of musculoskeletal manifestations, while no such association was found with CD4 cell count measured at the time of diagnosis of primary disease (p=0.381-lndependent Mann-Whitney U Test).

Musculoskeletal manifestations were more common in children with a longer duration of HIV infection (p=0.003-lndependent-samples median test), and in those with Stage 4 HIV infection. (p=0.009-Fisher's exact test) Also, these were found to be more freguent in children infected with HIV who are currently on HAART (p=0.013-Fisher's exact test).

Arthralgia was present in 5.22% of the study population, while myalgia occurred in 3.29%. Non-infective inflammatory arthropathies were found in 3 children (0.58%), and infective manifestations were found in 11 children, which included septic arthritis-4 (0.77%), myositis-4 (0.77%), and osteomyelitis-3 (0.58%). Presence of non-infective muscular manifestations were more common in malnourished children (p=0.044-Fisher's exact test), but there were no significant differences in infective (p=0.706-Fisher's exact test) or non-infective articular (p=0.817-Fisher's exact test) manifestations with respect to nutritional status (Table 2).

There was no significant association between the duration of the primary disease and prevalence of non-infective musculoskeletal manifestations (p=0.177-lndependent Mann-Whitney U Test); however, infective manifestations were found to be more prevalent with increased duration of disease (p=0.042-lndependent Mann-Whitney U Test). A lower CD4 count at the time of evaluation was significantly associated with increased prevalence of non-infective articular manifestations (p=0.013-lndependent sample median test) and infective manifestations (p=0.019-lndependent sample median test). Both infective and non-infective articular and muscular manifestations were found to be more common in the subgroup of children infected with HIV who were on anti-retroviral medications at the time of evaluation.

ANA was done in presence of arthralgia, arthritis, arthropathy, myositis, or any other manifestation suggestive of connective tissue diseases. RA factor was evaluated if arthritis or arthralgia was found. Out of 38 children, 4 showed ANA positivity (10.5%). All four were females, and belonged to the age group 9-19 years. RA factor was found in 7 of 34 children (20.6%).

Discussion

Over the years, many studies have explored different aspects of the vulnerable children living with HIV/AIDS (CLHIV) population. But evidence on musculoskeletal manifestations in CLHIV is scarce, and most of our knowledge is built on studies done in adults (22-31). Often patients neglect the early musculoskeletal symptoms because of more extensive involvement of other systems that is also what the treating physicians are often preoccupied with. With the use of HAART as a treatment modality for the primary disease, there has been a better control of the primary disease resulting in a longer disease-free life. Therefore, while considering the long-term disease-free survival of these children in the present scenario, musculoskeletal manifestations become more and more significant. There are only a few studies worldwide on musculoskeletal manifestations involving pediatric population with HIV (10-14). One recent single-center case series from northern India has reported four children with HIV infection who developed arthritis (32). So, the index study is the first large-scale prospective study of its kind to address the spectrum of rheumatological manifestations in children infected with HIV.

Musculoskeletal manifestations were found in 11.2% of the study population, which is significantly higher than the prevalence in the general population. In an earlier study, Goodman et al. (33) concluded that musculoskeletal pain is present in 4-30% of children in a non-clinic setting, whereas a report from the Royal Children's Hospital in Melbourne found that 1.6% of the children in emergency or outpatient department had a non-traumatic muscle or joint problem (34). However, a recent study by Sabui et al. (35) reported that approximately 10.6% of healthy school-going children of foothill region of Himalayas were suffering from some form of rheumatological problems as identified by pGALS screening.

In this study, musculoskeletal manifestations were found to be more familiar in the age group 9-19 years. This is because a child's belief about the physical nature of his/her disease greatly influences the amount of emotional distress he/she experiences and even his/her compliance to therapy.

Prevalence of musculoskeletal manifestation was found to be more in malnourished children. Also, musculoskeletal manifestations were common in advanced stage of HIV infection manifested by lower CD4 count, and in clinical Stage 4 of the disease. Most of them were currently on anti-retroviral drugs. Thus, it indicates that where the disease is extensive, rheumatological manifestations are common.

There are few notable studies with similar objectives in the general population. Munoz Fernandez et al. (36) conducted a study on 556 patients aged <30 years, with comparable results. They concluded that musculoskeletal manifestations were mainly not due to HIV infection. Rheumatological features were found in 11% of study population, whereas 11.3% of children manifested musculoskeletal problem in this study. The prevalence of arthralgia and myalgia were found to be 4.5% and 1.6% by Munoz Fernandez et al. (36), whereas in our study, 5.2% and 3.3% children had arthralgia and myalgia, respectively. Staphylococcus aureus was the commonest cause of infectious musculoskeletal manifestation in both the studies (60% vs. 45%).

In their 2008 study, Yao et al. (5) reported that rheumatological manifestations were present in 9% patients, with arthritis/arthralgia being the commonest (5.5%), followed by septic arthritis (1%), and osteomyelitis (0.9%) which compares well with our results.

A 1991 study by Calabrese et al. (37) evaluated 117 patients after a mean of 24.6 months, and concluded that patients with articular disease tend to have a more progressive HIV infection, and are more prone to experience progressive disease due to clinical AIDS or death. Though we could not draw such conclusion from our study due to lack of long-term follow-up, this study also found musculoskeletal manifestations to be more prevalent in advanced stages of the disease.

This study is a single-center observational study limited by the lack of long-term follow-up that might have resulted in missing some musculoskeletal manifestations in the CLHIV population over a longer time period. Also, this being a single-center study, variation in the study population from multiple centers could not be commented upon. However, to the best of our knowledge, this study is the largest and first of its kind to explore the range of musculoskeletal manifestations, and their clinical correlates exclusively in children with HIV infection from developing country. Our study shows that a significant disease burden of musculoskeletal problems exists among the CLHIV population. Further long-term multicentric studies are imperative to get a more representative picture and to better understand the long-term outcomes.

Ethics Committee Approval: Ethics committee approval was received for this study from the Kolkata Medical College Ethics Committee for Human Research.

Informed Consent: Written informed consent was obtained from the patients who participated in this study.

Peer-review: Externally peer-reviewed.

Author Contributions: Concept - R.K.M.; Design - R.K.M., T.B.; Supervision - T.B., R.K.M.; Data Collection and/or Processing - DC, T.B.; Analysis and/or Interpretation - D.C., T.B.; Literature Search - D.C., T.B., S.B.; Writing Manuscript - D.C., T.B., S.B.; Critical Review -R.M.K., T.S.; Patient Management -T.B., R.K.M., DC

Acknowledgements: Prof. Subhashis Bhattacharya (Ex In-charge) Prof. Kalpana Datta (In-charge) Paediatric Centre of Excellence for HIV/AIDS, Medical College, Kolkata and the staff of Regional ART Centre, Medical College, Kolkata.

Conflict of Interest: The authors have no conflict of interest to declare.

Financial Disclosure: The authors declared that this study has received no financial support.

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Debrup Chakladar, Rakesh K. Mondal, Tapas Kumar Sabui, Souravi Bhowmik, Tamoghna Biswas

ORCID IDs of the authors:

D.C.0000-0002-3564-600X;

R.K.M. 0000-0002-2241-3514;

T K.S. 0000-0003-0009-9074;

S.B. 0000-0001-5836-5254;

T.B. 0000-0003-2114-8197.

Department of Pediatric Medicine, Kolkata Medical College, Kolkata, India

Address for Correspondence:

Rakesh K Mondal, Department of Pediatric Medicine, Kolkata Medica College, Kolkata, India

E-mail; ivanrakesh2001@gmail.com

Submitted: 7 March 7018

Accepted: 14 July 2018

Available Online Date: 12 October 2018

DOI:10.5152/eurjrheum.2018.18045
Table 1. Demographic attributes of the study population

                                                 Std.
                             Maximum  Minimum    deviation    Mean

Age (in years)                 19        3       3.446        9.62
Age of diagnosis (in years)    14      0.5       3.774        5.32
CD4 count at time
of diagnosis (/[micro]L)     1951      113     251.08       786.02
CD4 count at time of
evaluation (/[micro]L)       1293       14     255.955      516.81
WHO clinical staging            4        1       0.927        2.50
Duration of primary
disease (in years)             17.5      1       3.004        7.30

                              Std error
                              of mean

Age (in years)                0.152
Age of diagnosis (in years)   0.122
CD4 count at time
of diagnosis (/[micro]L)     11.042
CD4 count at time of
evaluation (/[micro]L)       11.257
WHO clinical staging          0.041
Duration of primary
disease (in years)            0.132

Table 2. Different musculoskeletal manifestations in children infected
with HIV with respect to age, gender, and presence of malnutrition in
these children

                                      Female
                           3-8 years           9-19 years
Musculoskeletal
manifestations            Absent      Present  Absent

Non-infective
articular
manifestations   Absent     84         14       101

                 Present     4          0         9
Total                       88         14       110

                  Gender
                                           Male
                                3-8 years           9-19 years
                 Malnutrition
Musculoskeletal
manifestations   Present       Absent      Present  Absent

Non-infective
articular
manifestations    34            84          16       117

                   3             4           1         6
Total             37            88          17       123

                                         p and Significance
Musculoskeletal
manifestations   Present  Total         (Fisher's exact test)

Non-infective
articular
manifestations    37       487            0.037 (*)
                                         (Significant)
                   3        30            0.578 (**)
                                         (Not Significant)
Total             40       517(100%)      0.817 (***)
                                          (Not Significant)

(*) Comparison of non-infective articular manifestations between
different age groups

(**) Comparison of non-infective articular manifestations between
gender

(***) Comparison of non-infective articular manifestations with
presence of malnutrition

                                      Female
                           3-8 years           9-19 years
Musculoskeletal
manifestations             Absent     Present  Absent

Non-infective
muscular
manifestations    Absent    86         14      108
                  Present    2          0        2
Total                       88         14      110
                  Gender
                                          Male
                               3-8 years           9-19 years
                 Malnutrition
Musculoskeletal
manifestations   Present       Absent     Present  Absent

Non-infective
muscular
manifestations   33            86         16       119
                  4             2          1         4
Total            37            88         17       123

                                     p and Significance
Musculoskeletal
manifestations   Present  Total      (Fisher's exact test)

Non-infective
muscular
manifestations   38       500        0.045 (*)
                                     (Significant)
                  2        17        0.753 (**)
                                     (Not Significant)
Total            40       517(100%)  0.044 (***)
                                     (Significant)

(*) Comparison of non-infective muscular manifestations in different
age group

(**) Comparison of non-infective muscular manifestations with gender

(***) Comparison of non-infective muscular manifestations with presence
of malnutrition

                                     Female
                          3-8 years           9-19 years

Musculoskeletal
manifestations            Absent     Present    Absent
Infective
manifestations   Absent    87          13        107
                 Present    1           1          3
 Total                     88          14        110

                  Gender
                                           Male
                               3-8 years           9-19 years
                 Malnutrition

Musculoskeletal
manifestations   Present       Absent     Present  Absent
Infective
manifestations   36            87         17       120

                  1             1          0        3
Total            37            88         17       123

                 Malnutrition         p and Significance
                 Present  Total      (Fisher's exact test)

Musculoskeletal  39       506        0.538 (*)
manifestations                       (Not Significant)
Infective         1        11        0.765 (**)
manifestations                       (Not Significant)
                 40       517(100%)  0.706 (***)
                                     (Not Significant)
Total

(*) Comparison of infective manifestations in different age group

(**) Comparison of infective manifestations with gender

(***) Comparison of infective manifestations with presence of
malnutrition
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Title Annotation:Original Article
Author:Chakladar, Debrup; Mondal, Rakesh K.; Sabui, Tapas Kumar; Bhowmik, Souravi; Biswas, Tamoghna
Publication:European Journal of Rheumatology
Article Type:Report
Date:Mar 1, 2019
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