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Spondyloarthritis, HIV and the Lessons of History
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The history of the construct of spondyloarthritis as it evolved from ankylosing spondylitis from the late 19th century until now is remarkable to me. Why? Because it represents a culmination of careful observation by many who separated the disorder from the myriad of etiologies of structural and inflammatory back pain, combined these observations with careful epidemiology, took advantage of advances in musculoskeletal imaging and therapy and, ultimately, birthed the field of immunogenic investigation of disease with the discovery of the association of spondyloarthritis and B27.
For those of us who have been around long enough to see many of these advances and who have been allowed to puzzle over many of the milestones in real time, it has been satisfying. Today, opportunities abound to make meaningful differences in the lives of patients with spondyloarthritis (SpA). We now have tools for earlier recognition, as well as growing numbers of targeted therapeutics that — despite some conflicting evidence — leave little doubt these offer profound benefits for our patients.
In this issue’s Cover Story, we are pleased to publish a discussion on the advances and challenges in the spodyloarthropathies. It gave me pause to share with you a recent case that dramatically puts this discussion into perspective.
A Witness to Progress
This remarkable case makes me shake my head and feel gratitude for serving witness to the progress we have made in two devastating diseases. We recently cared for a young man who presented with debilitating peripheral SpA and who was HLA-B27 positive. This alone was remarkable enough given its severity and activity, but to add to the challenge was that his rheumatic disorder served as the gateway diagnosis for advanced HIV infection. He had significant peripheral joint swelling and damage with flexion contractures, was barely able to ambulate and was found to be in an advanced state of CD4-cell depletion.
At an earlier stage of my career, I would have been powerless to control his HIV infection, which surely would have continued to rapidly progress, nor to control his rheumatic manifestations with this fulminant SpA-like picture. In fact, having practiced HIV medicine for more than 35 years, this felt like a bad dream or at least a déjà vu moment. His case was far more representative of the early and dark days when patients often presented with advanced disease, which is uncommon now. I couldn’t help but recall our “therapeutic armamentarium” of ineffective antiviral therapies and the rare but dramatic presentations of bizarre and severe rheumatic syndromes which are now thankfully rare.
Lessons Learned
Just think of this man presenting before 1998, when we did not have the effective antiviral therapies which ultimately would be used together in combination antiretroviral therapy (cART). Furthermore, in 1998 we did not have a biologic option for SpA, as the tumor necrosis factor (TNF) inhibitors were just advancing to regulatory approval. Fast forward this patient to 2016 or 2017 where now we could first control his HIV infection with cART, allow him to reconstitute his immune system and then start him on a regimen that included a TNF inhibitor. We recently saw him back in clinic. His HIV viral load was non-detectable, his CD4 count nearly 800 cells/mm3 and he announced he had returned to jogging.
There you have it – a man with an infection, which at an earlier stage of my career was not even microbiologically known, but today is readily diagnosable and eminently treatable. His rheumatic disease at that earlier time might not have been recognized as SpA and certainly was not within our power to put into remission.
I will close by telling you what made it special. I managed this case with my daughter Cassie, who was starting her rheumatology-infectious disease combined fellowship. It was like a case from a previous era just appeared in our clinic – a case with so much to teach and a man for whom we had so much to offer. I wonder to myself what I would have told my fellow in 1998 about this young man, his disease and our plan? There are so many lessons and so much history in one man’s case. I know she will not forget it.
Thanks for reading. Please share your thoughts with me by email at calabrl@ccf.org or follow me on Twitter @LCalabreseDO or @HealioRheum.
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- Leonard H. Calabrese, DO, is the Chief Medical Editor, Healio Rheumatology, and Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, and RJ Fasenmyer Chair of Clinical Immunology at the Cleveland Clinic.
Disclosure: Calabrese reports he is a consultant for Genentech, Pfizer, Bristol-Myers Squibb, GlaxoSmithKline, Sanofi, Jansen and AbbVie; and is on the speakers bureau for Genentech, AbbVie and Bristol-Myers Squibb and Crescendo Bioscience.