Figure 1
Teaching Case
SectionMusculoskeletal system
Case TypeClinical Cases
AuthorsAmbra Sangiovanni, M.D., Enrico Colli Tibaldi, M.D., Ferdinando Draghi, M.D.
Connected authors
50 years, female
A 50-year-old woman, HIV-positive, receiving HAART (highly active antiretroviral therapy), presented with atraumatic pain and swelling in both the ankles and feet, which she had had for years and which had recently become acute. She had never received corticosteroids and there were no other risk factors.
HIV-related osteonecrosis of the ankles and feet
Osteochondral fracture [13]
Osteoarthritis [13]
Neuropathic osteoarthropathy [13]
Ultrasound and X-ray did not show pathological features.
Magnetic resonance imaging (MRI) was performed using a Symphony Magnetom Maestro Class 1.5-T MRI system (Siemens Medical Solutions, Malvern, NJ, USA). Sagittal T1-weighted, sagittal, coronal and axial DP fat sat sequences were performed. Bilaterally, MRI showed areas of abnormal signal, with irregular margins in the distal third of the tibia, in the astragalus and calcaneus, related to severe subchondral ischaemia and bone oedema, suggesting osteonecrosis.
Tibio-astragalic and subastragalic joint effusion and insufficiency fractures of both the astragalus bones and of the proximal epiphysis of left tibia coexisted.
Magnetic resonance imaging (MRI) was performed using a Symphony Magnetom Maestro Class 1.5-T MRI system (Siemens Medical Solutions, Malvern, NJ, USA). Sagittal T1-weighted, sagittal, coronal and axial DP fat sat sequences were performed. Bilaterally, MRI showed areas of abnormal signal, with irregular margins in the distal third of the tibia, in the astragalus and calcaneus, related to severe subchondral ischaemia and bone oedema, suggesting osteonecrosis.
Tibio-astragalic and subastragalic joint effusion and insufficiency fractures of both the astragalus bones and of the proximal epiphysis of left tibia coexisted.
Osteonecrosis (or ‘avascular necrosis of bone’) derives from the death of cellular elements of bone causing skeletal pain. It is supposed to be the result of the interruption of the blood supply to the affected bone [1] and it has been attributed to: altered arterial blood viscosity, impaired arterial blood supply, the replacement of intraosseous vascular tissue with non-vascular tissue, a decreased arterial inflow due to increased intraosseous pressure, or hypertension caused by reduced venous drainage [2].
Alcohol abuse, dyslipidaemia, haemoglonbinopathies, hypercoagulable states and systemic corticosteroids are the most common risk factors for osteonecrosis.
Osteonecrosis is described as a rare complication in patients with HIV [3-4], with unclear and multifactorial pathogenesis [2-3]. The main risk factors are: anti-phospholipid and anti-cardiolipin antibodies [5], increased triglycerides, chronic treatment with steroids or megestrol acetate, caloric deprivation [2-6], and the use of protease inhibitors [7].
The role of HAART, instead, is still controversial.
It has been associated with several metabolic complications, determining osteopenia and osteoporosis [8]. The mechanisms involved are: (1) enhanced humoral immunity, causing increased production of anti-protein S or antiphospholipid antibodies; (2) hyperlipidemia and (3) abnormal fat distribution [9-10-1], which determine peripheral insulin resistance, inhibition of lipoprotein-lipase (by TNF-α), suppression of HIV replication and changes in endocrine homeostasis [11]. Immunomodulating effects are also associated with rise in serum osteocalcin levels [12].
In HIV-infected patients, bone disease can affect one or multiple sites and causes pain and swelling of the joints involved. In particular, in the English language literature, the hip represents the most common site of involvement, followed by the knee and the shoulder [7], while the ankle, especially bilaterally, is very rarely involved.
MRI and scintigraphy are currently the best methods to recognize the condition and establish a correct diagnosis [3], while the role of conventional X-ray and ultrasound appears unremarkable.
MRI can show several pathological features, which can be surely related to ischaemia, suggesting osteonecrosis.
MRI appears to be the most reliable and safe imaging technique available in the recognition of osteonecrosis.
Moreover, it has been suggested that systemic corticosteroids can represent a risk factor for osteonecrosis. In spite of this, our patient has received HAART, but has never been treated with corticosteroids.
Awareness of its potentiality should induce MRI to be encouraged as a valid method to diagnose osteonecrosis.
In addition, clinicians should be aware that HAART can play a leading role in determining the onset of osteonecrosis in HIV-infected patients, independently of other risk factors, especially systemic corticosteroids.
Alcohol abuse, dyslipidaemia, haemoglonbinopathies, hypercoagulable states and systemic corticosteroids are the most common risk factors for osteonecrosis.
Osteonecrosis is described as a rare complication in patients with HIV [3-4], with unclear and multifactorial pathogenesis [2-3]. The main risk factors are: anti-phospholipid and anti-cardiolipin antibodies [5], increased triglycerides, chronic treatment with steroids or megestrol acetate, caloric deprivation [2-6], and the use of protease inhibitors [7].
The role of HAART, instead, is still controversial.
It has been associated with several metabolic complications, determining osteopenia and osteoporosis [8]. The mechanisms involved are: (1) enhanced humoral immunity, causing increased production of anti-protein S or antiphospholipid antibodies; (2) hyperlipidemia and (3) abnormal fat distribution [9-10-1], which determine peripheral insulin resistance, inhibition of lipoprotein-lipase (by TNF-α), suppression of HIV replication and changes in endocrine homeostasis [11]. Immunomodulating effects are also associated with rise in serum osteocalcin levels [12].
In HIV-infected patients, bone disease can affect one or multiple sites and causes pain and swelling of the joints involved. In particular, in the English language literature, the hip represents the most common site of involvement, followed by the knee and the shoulder [7], while the ankle, especially bilaterally, is very rarely involved.
MRI and scintigraphy are currently the best methods to recognize the condition and establish a correct diagnosis [3], while the role of conventional X-ray and ultrasound appears unremarkable.
MRI can show several pathological features, which can be surely related to ischaemia, suggesting osteonecrosis.
MRI appears to be the most reliable and safe imaging technique available in the recognition of osteonecrosis.
Moreover, it has been suggested that systemic corticosteroids can represent a risk factor for osteonecrosis. In spite of this, our patient has received HAART, but has never been treated with corticosteroids.
Awareness of its potentiality should induce MRI to be encouraged as a valid method to diagnose osteonecrosis.
In addition, clinicians should be aware that HAART can play a leading role in determining the onset of osteonecrosis in HIV-infected patients, independently of other risk factors, especially systemic corticosteroids.
References
[1] Monier P, McKown K, Bronze MS (2000) Osteonecrosis complicating highly active antiretroviral therapy in patients infected with human immunodeficiency virus. Clinical Infectious Diseases 31(6):1488-92 (PMID: 11096017)
[2] Koller E, Mann M, Malozowski S, Bacsanyi J, Gibert C (2000) Aseptic necrosis in HIV seropositive patients: a possible etiologic role for megestrol acetate. Patient Care STDS 14(8):405-10 (PMID: 10977969)
[3] Meyer D, Behrens G, Stoll M, Schmidt RE (2000) Osteonecrosis: a rare complication of HIV infection. Association with certain risk factors. MMW - Fortschritte der Medizin 142 Suppl 1:64-7 (PMID: 10863317)
[4] Lima GA, Verdeal JC, Farias ML (2005) Osteonecrosis in patients with acquired immunodeficiency syndrome (AIDS): report of two cases and review of the literature. Arquivos Brasileiros de Endocrinologia & Metabologia 49(6):996-9 (PMID: 16544026)
[5] Miller KD, Masur H, Jones EC, Joe GO, Rick ME, Kelly GG, Mican JM, Liu S, Gerber LH, Blackwelder WC, Falloon J, Davey RT, Polis MA, Walker RE, Lane HC, Kovacs JA (2002) High prevalence of osteonecrosis of the femoral head in HIV-infected adults. Annals of Internal Medicine 137(1):17-25 (PMID: 12093241)
[6] Sighinolfi L, Carradori S, Ghinelli F (2000) Avascular necrosis of the femoral head: a side effect of highly active antiretroviral therapy (HAART) in HIV patients?. Infection 28(4):254-5 (PMID: 10961537)
[7] Brown P, Crane L (2001) Avascular necrosis of bone in patients with human immunodeficiency virus infection: report of 6 cases and review of the literature. Clinical Infectious Diseases 32(8):1221-6 (PMID: 11283813)
[8] Tebas P, Powderly WG, Claxton S, Marin D, Tantisiriwat W, Teitelbaum SL, Yarasheski KE (2000) Accelerated bone mineral loss in HIV-infected patients receiving potent antiretroviral therapy. AIDS 14(4):F63-7 (PMID: 10770534)
[9] Meyer D, Behrens G, Schmidt RE, Stoll M (1999) Osteonecrosis of the femoral head in patients receiving HIV protease inhibitors. AIDS 13(9):1147-8 (PMID: 10397552)
[10] Wang GJ, Lennox DW, Reger SI, Stamp WG, Hubbard SL (1981) Cortisone-induced intrafemoral head pressure change and its response to a drilling decompression method. Clin Orthop Relat Res (159):274-8 (PMID: 7285465)
[11] Calza L, Manfredi R, Chiodo F (2003) Statins and fibrates for the treatment of hyperlipidaemia in HIV-infected patients receiving HAART. AIDS 17(6):851-9 (PMID: 12660532)
[12] Aukrust P, Haug CJ, Ueland T, Lien E, Müller F, Espevik T, Bollerslev J, Frøland SS (1999) Decreased bone formative and enhanced resorptive markers in human immunodeficiency virus infection: indication of normalization of the bone-remodeling process during highly active antiretroviral therapy. J Clin Endocrinol Metab 84(1):145-50 (PMID: 9920075)
[13] Chew F, Mulcahy H, Ha AS (2012) Musculoskeletal Imaging: A Teaching file. WOLTERS KLUER – LIPPINCOTT WILLIAMS & WILKINS, 3rd edition 502
Case information
| URL: | https://www.eurorad.org/case/13228 |
| DOI: | 10.1594/EURORAD/CASE.13228 |
| ISSN: | 1563-4086 |
License
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Figure 1
Draghi F., Radiology Institute, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
Figure 2
Draghi F., Radiology Institute, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
Figure 3
Draghi F., Radiology Institute, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
Figure 4
Draghi F., Radiology Institute, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
Figure 5
Draghi F., Radiology Institute, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
Figure 6
Draghi F., Radiology Institute, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy