Semin Musculoskelet Radiol 2011; 15(5): 541-553
DOI: 10.1055/s-0031-1293499
© Thieme Medical Publishers

Musculoskeletal Infection in Acquired Immunodeficiency Syndrome

Nuttaya Pattamapaspong1 , Worawit Louthrenoo2
  • 1Department of Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
  • 2Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
Further Information

Publication History

Publication Date:
11 November 2011 (online)


Musculoskeletal infection is one of the common manifestations of patients infected with human immunodeficiency virus and acquired immunodeficiency syndrome. With immune deficiency, patients are susceptible to a variety of nonopportunistic and opportunistic infections that can result in significant morbidity and mortality. Infection can involve any anatomical compartments resulting in infectious arthritis, osteomyelitis, pyomyositis, and soft tissue and skin infection. Imaging plays an important role in the early diagnosis and treatment planning for these patients. This article reviews the clinical manifestations of musculoskeletal infection together with reported causative organisms. We discuss the role of imaging and present radiological examples.


  • 1 Louthrenoo W. Rheumatic manifestations of human immunodeficiency virus infection.  Curr Opin Rheumatol. 2008;  20 (1) 92-99
  • 2 Steinbach L S, Tehranzadeh J, Fleckenstein J L, Vanarthos W J, Pais M J. Human immunodeficiency virus infection: musculoskeletal manifestations.  Radiology. 1993;  186 (3) 833-838
  • 3 Berman A, Espinoza L R, Diaz J D et al.. Rheumatic manifestations of human immunodeficiency virus infection.  Am J Med. 1988;  85 (1) 59-64
  • 4 Hughes R A, Macatonia S E, Rowe I F, Keat A C, Knight S C. The detection of human immunodeficiency virus DNA in dendritic cells from the joints of patients with aseptic arthritis.  Br J Rheumatol. 1990;  29 (3) 166-170
  • 5 Ventura G, Gasparini G, Lucia M B et al.. Osteoarticular bacterial infections are rare in HIV-infected patients. 14 cases found among 4,023 HIV-infected patients.  Acta Orthop Scand. 1997;  68 (6) 554-558
  • 6 Medina-Rodriguez F, Guzman C, Jara L J et al.. Rheumatic manifestations in human immunodeficiency virus positive and negative individuals: a study of 2 populations with similar risk factors.  J Rheumatol. 1993;  20 (11) 1880-1884
  • 7 Muñoz Fernández S, Cardenal A, Balsa A et al.. Rheumatic manifestations in 556 patients with human immunodeficiency virus infection.  Semin Arthritis Rheum. 1991;  21 (1) 30-39
  • 8 Monteagudo I, Rivera J, Lopez-Longo J, Cosin J, Garcia-Monforte A, Carreño L. AIDS and rheumatic manifestations in patients addicted to drugs. An analysis of 106 cases.  J Rheumatol. 1991;  18 (7) 1038-1041
  • 9 Louthrenoo W. Musculoskeletal manifestations of HIV infection in Thailand: an analysis of 100 cases.  J Clin Rheumatol. 1997;  3 (5) 258-268
  • 10 Blanche P, Taelman H, Saraux A et al.. Acute arthritis and human immunodeficiency virus infection in Rwanda.  J Rheumatol. 1993;  20 (12) 2123-2127
  • 11 Belzunegui J, Santisteban M, Gorordo M et al.. Osteoarticular mycobacterial infections in patients with the human immunodeficiency virus.  Clin Exp Rheumatol. 2004;  22 (3) 343-345
  • 12 Hirsch R, Miller S M, Kazi S, Cate T R, Reveille J D. Human immunodeficiency virus-associated atypical mycobacterial skeletal infections.  Semin Arthritis Rheum. 1996;  25 (5) 347-356
  • 13 Vassilopoulos D, Chalasani P, Jurado R L, Workowski K, Agudelo C A. Musculoskeletal infections in patients with human immunodeficiency virus infection.  Medicine (Baltimore). 1997;  76 (4) 284-294
  • 14 Calabrese L H, Kirchner E, Shrestha R. Rheumatic complications of human immunodeficiency virus infection in the era of highly active antiretroviral therapy: emergence of a new syndrome of immune reconstitution and changing patterns of disease.  Semin Arthritis Rheum. 2005;  35 (3) 166-174
  • 15 Marquez J, Restrepo C S, Candia L, Berman A, Espinoza L R. Human immunodeficiency virus-associated rheumatic disorders in the HAART era.  J Rheumatol. 2004;  31 (4) 741-746
  • 16 Barzilai A, Varon D, Martinowitz U, Heim M, Schulman S. Characteristics of septic arthritis in human immunodeficiency virus-infected haemophiliacs versus other risk groups.  Rheumatology (Oxford). 1999;  38 (2) 139-142
  • 17 Bookstaver P B, Rudisill C N. Primary meningococcal arthritis as initial presentation in a previously undiagnosed HIV-infected patient.  South Med J. 2009;  102 (4) 438-439
  • 18 Zalavras C G, Dellamaggiora R, Patzakis M J, Bava E, Holtom P D. Septic arthritis in patients with human immunodeficiency virus.  Clin Orthop Relat Res. 2006;  451 46-49
  • 19 Louthrenoo W. Musculoskeletal infections in patients infected with human immunodeficiency virus.  J Infect Dis Antimicrob Agents. 1995;  12 5-9
  • 20 Bureau N J, Cardinal E. Imaging of musculoskeletal and spinal infections in AIDS.  Radiol Clin North Am. 2001;  39 (2) 343-355
  • 21 Tehranzadeh J, Ter-Oganesyan R R, Steinbach L S. Musculoskeletal disorders associated with HIV infection and AIDS. Part I: infectious musculoskeletal conditions.  Skeletal Radiol. 2004;  33 (5) 249-259
  • 22 Restrepo C S, Lemos D F, Gordillo H et al.. Imaging findings in musculoskeletal complications of AIDS.  Radiographics. 2004;  24 (4) 1029-1049
  • 23 Ashrani A A, Key N S, Soucie J M, Duffy N, Forsyth A, Geraghty S. Universal Data Collection Project Investigators . Septic arthritis in males with haemophilia.  Haemophilia. 2008;  14 (3) 494-503
  • 24 Gregg-Smith S J, Pattison R M, Dodd C A, Giangrande P L, Duthie R B. Septic arthritis in haemophilia.  J Bone Joint Surg Br. 1993;  75 (3) 368-370
  • 25 Boutin R D, Brossmann J, Sartoris D J, Reilly D, Resnick D. Update on imaging of orthopedic infections.  Orthop Clin North Am. 1998;  29 (1) 41-66
  • 26 Magid D, Fishman E K. Musculoskeletal infections in patients with AIDS: CT findings.  AJR Am J Roentgenol. 1992;  158 (3) 603-607
  • 27 Lertsrisatit P, Nantiruj K, Totemchokchyakarn K, Janwityanujit S. Extraspinal tuberculous arthritis in HIV era.  Clin Rheumatol. 2007;  26 (3) 319-321
  • 28 Jellis J E. Human immunodeficiency virus and osteoarticular tuberculosis.  Clin Orthop Relat Res. 2002;  (398) 27-31
  • 29 Nalaboff K M, Rozenshtein A, Kaplan M H. Imaging of Mycobacterium avium-intracellulare infection in AIDS patients on highly active antiretroviral therapy: reversal syndrome.  AJR Am J Roentgenol. 2000;  175 (2) 387-390
  • 30 Moore S L, Rafii M. Imaging of musculoskeletal and spinal tuberculosis.  Radiol Clin North Am. 2001;  39 (2) 329-342
  • 31 Agarwal S, Caplivski D, Bottone E J. Disseminated tuberculosis presenting with finger swelling in a patient with tuberculous osteomyelitis: a case report.  Ann Clin Microbiol Antimicrob. 2005;  4 18
  • 32 De Vuyst D, Vanhoenacker F, Gielen J, Bernaerts A, De Schepper A M. Imaging features of musculoskeletal tuberculosis.  Eur Radiol. 2003;  13 (8) 1809-1819
  • 33 Hong S H, Kim S M, Ahn J M, Chung H W, Shin M J, Kang H S. Tuberculous versus pyogenic arthritis: MR imaging evaluation.  Radiology. 2001;  218 (3) 848-853
  • 34 De Backer A I, Mortelé K J, Vanhoenacker F M, Parizel P M. Imaging of extraspinal musculoskeletal tuberculosis.  Eur J Radiol. 2006;  57 (1) 119-130
  • 35 Teo H EL, Peh W CG. Skeletal tuberculosis in children.  Pediatr Radiol. 2004;  34 (11) 853-860
  • 36 Wang M N, Chen W M, Lee K S, Chin L S, Lo W H. Tuberculous osteomyelitis in young children.  J Pediatr Orthop. 1999;  19 (2) 151-155
  • 37 Lefkowitz R A, Singson R D. Considering Mycobacterium haemophilum in the differential diagnosis for lytic bone lesions in AIDS patients who present with ulcerating skin lesions.  Skeletal Radiol. 1998;  27 (6) 334-336
  • 38 Redfern D J, Coleridge S D, Bendall S P. AIDS-related ankle arthropathy: Mycobacterium avium-intracellulare infection.  J Bone Joint Surg Br. 2004;  86 (2) 279-281
  • 39 Resnick D. Osteomyelitis, septic arthritis, and soft tissue infection: organisms. In: Resnick D, ed. Diagnosis of Bone and Joint Disorders. 4th ed. Philadelphia, PA: WB Saunders; 2002: 2510-2624
  • 40 Madariaga M G, Jalali Z, Swindells S. Clinical utility of interferon gamma assay in the diagnosis of tuberculosis.  J Am Board Fam Med. 2007;  20 (6) 540-547
  • 41 Leibert E, Schluger N W, Bonk S, Rom W N. Spinal tuberculosis in patients with human immunodeficiency virus infection: clinical presentation, therapy and outcome.  Tuber Lung Dis. 1996;  77 (4) 329-334
  • 42 Edelstein H, McCabe R. Candida albicans septic arthritis and osteomyelitis of the sternoclavicular joint in a patient with human immunodeficiency virus infection.  J Rheumatol. 1991;  18 (1) 110-111
  • 43 Parra-Ruiz J, Peña-Monje A, Tomas-Jimenez C, Antelo-Lorenzo R, Escobar-Lara T, Hernández-Quero J. Septic arthritis due to Absidia corymbifera in a patient with HIV-1 infection.  Infection. 2008;  36 (3) 279-281
  • 44 Deng Z, Ribas J L, Gibson D W, Connor D H. Infections caused by Penicillium marneffei in China and Southeast Asia: review of eighteen published cases and report of four more Chinese cases.  Rev Infect Dis. 1988;  10 (3) 640-652
  • 45 Hilmarsdottir I, Meynard J L, Rogeaux O et al.. Disseminated Penicillium marneffei infection associated with human immunodeficiency virus: a report of two cases and a review of 35 published cases.  J Acquir Immune Defic Syndr. 1993;  6 (5) 466-471
  • 46 Louthrenoo W, Thamprasert K, Sirisanthana T. Osteoarticular penicilliosis marneffei. A report of eight cases and review of the literature.  Br J Rheumatol. 1994;  33 (12) 1145-1150
  • 47 Grover S B, Midha N, Gupta M, Sharma U, Talib V H. Imaging spectrum in disseminated histoplasmosis: case report and brief review.  Australas Radiol. 2005;  49 (2) 175-178
  • 48 Avenel G, Goëb V, Abboud P, Ait-Abdesselam T, Vittecoq O. Atypical forms of syphilis: two cases.  Joint Bone Spine. 2009;  76 (3) 293-295
  • 49 Burgoyne M, Agudelo C, Pisko E. Chronic syphilitic polyarthritis mimicking systemic lupus erythematosus/rheumatoid arthritis as the initial presentation of human immunodeficiency virus infection.  J Rheumatol. 1992;  19 (2) 313-315
  • 50 Bickels J, Ben-Sira L, Kessler A, Wientroub S. Primary pyomyositis.  J Bone Joint Surg Am. 2002;  84-A (12) 2277-2286
  • 51 Fayad L M, Carrino J A, Fishman E K. Musculoskeletal infection: role of CT in the emergency department.  Radiographics. 2007;  27 (6) 1723-1736
  • 52 Chiedozi L C. Pyomyositis. Review of 205 cases in 112 patients.  Am J Surg. 1979;  137 (2) 255-259
  • 53 Fleckenstein J L, Burns D K, Murphy F K, Jayson H T, Bonte F J. Differential diagnosis of bacterial myositis in AIDS: evaluation with MR imaging.  Radiology. 1991;  179 (3) 653-658
  • 54 Bélec L, Di Costanzo B, Georges A J, Gherardi R. HIV infection in African patients with tropical pyomyositis.  AIDS. 1991;  5 (2) 234
  • 55 Medina F, Fuentes M, Jara L J, Barile L, Miranda J M, Fraga A. Salmonella pyomyositis in patients with the human immunodeficiency virus.  Br J Rheumatol. 1995;  34 (6) 568-571
  • 56 Vilades C, Garcia-Queralt R, Rivas I, Vidal F, Richart C. Pyomyositis due to Escherichia coli in a patient infected by HIV.  Br J Rheumatol. 1994;  33 (4) 404-405
  • 57 Widrow C A, Kellie S M, Saltzman B R, Mathur-Wagh U. Pyomyositis in patients with the human immunodeficiency virus: an unusual form of disseminated bacterial infection.  Am J Med. 1991;  91 (2) 129-136
  • 58 Pouchot J, Vinceneux P, Barge J, Laparre F, Boussougant Y, Michon C. Tuberculous polymyositis in HIV infection.  Am J Med. 1990;  89 (2) 250-251
  • 59 Hawkins C C, Gold J W, Whimbey E et al.. Mycobacterium avium complex infections in patients with the acquired immunodeficiency syndrome.  Ann Intern Med. 1986;  105 (2) 184-188
  • 60 Chupp G L, Alroy J, Adelman L S, Breen J C, Skolnik P R. Myositis due to Pleistophora (Microsporidia) in a patient with AIDS.  Clin Infect Dis. 1993;  16 (1) 15-21
  • 61 Goel D, Prayaga A K, Rao N, Damodaram P. Histoplasmosis as a cause of nodular myositis in an AIDS patient diagnosed on fine needle aspiration cytology. A case report.  Acta Cytol. 2007;  51 (1) 89-91
  • 62 Louthrenoo W, Mahanuphab P, Sanguanmitra P, Thamprasert K. Trichinosis mimicking polymyositis in a patient with human immunodeficiency virus infection.  Br J Rheumatol. 1993;  32 (11) 1025-1026
  • 63 Biviji A A, Paiement G D, Steinbach L S. Musculoskeletal manifestations of human immunodeficiency virus infection.  J Am Acad Orthop Surg. 2002;  10 (5) 312-320
  • 64 Chau C L, Griffith J F. Musculoskeletal infections: ultrasound appearances.  Clin Radiol. 2005;  60 (2) 149-159
  • 65 Major N M, Tehranzadeh J. Musculoskeletal manifestations of AIDS.  Radiol Clin North Am. 1997;  35 (5) 1167-1189
  • 66 Soler R, Rodríguez E, Aguilera C, Fernández R. Magnetic resonance imaging of pyomyositis in 43 cases.  Eur J Radiol. 2000;  35 (1) 59-64
  • 67 Gordon B A, Martinez S, Collins A J. Pyomyositis: characteristics at CT and MR imaging.  Radiology. 1995;  197 (1) 279-286
  • 68 Coopman S A, Johnson R A, Platt R, Stern R S. Cutaneous disease and drug reactions in HIV infection.  N Engl J Med. 1993;  328 (23) 1670-1674
  • 69 Hsieh Y H, Rothman R E, Bartlett J G, Yang S, Kelen G D. HIV seropositivity predicts longer duration of stay and rehospitalization among nonbacteremic febrile injection drug users with skin and soft tissue infections.  J Acquir Immune Defic Syndr. 2008;  49 (4) 398-405
  • 70 Fournier S, Pialoux G, Feuillie V, Fleury J, Dupont B. Edwardsiella tarda septicemia with cellulitis in a patient with AIDS.  Eur J Clin Microbiol Infect Dis. 1997;  16 (7) 551-553
  • 71 Manfredi R, Calza L, Chiodo F. Epidemiology and microbiology of cellulitis and bacterial soft tissue infection during HIV disease: a 10-year survey.  J Cutan Pathol. 2002;  29 (3) 168-172
  • 72 Mofredj A, Guerin J M, Leibinger F, Masmoudi R. Pneumococcal cellulitis in an HIV-infected adult.  Infection. 2000;  28 (3) 175-177
  • 73 Yoganathan K G, Blackwell A L. Unusual cause of acute scrotal cellulitis in an HIV positive man.  Sex Transm Infect. 2006;  82 (2) 187-188
  • 74 DeCoste S D, Dover J S. Kaposi's sarcoma and Mycobacterium avium-intracellulare with cellulitis in patient with acquired immunodeficiency syndrome.  J Am Acad Dermatol. 1989;  21 (3 Pt 1) 574-576
  • 75 Holladay K L, Carmichael J K. Mycobacterium haemophilum cellulitis and osteomyelitis in a man with AIDS.  J Am Board Fam Pract. 1996;  9 (2) 122-124
  • 76 Brothers T E, Tagge D U, Stutley J E, Conway W F, Del Schutte Jr H, Byrne T K. Magnetic resonance imaging differentiates between necrotizing and non-necrotizing fasciitis of the lower extremity.  J Am Coll Surg. 1998;  187 (4) 416-421
  • 77 Supparatpinyo K, Perriens J, Nelson K E, Sirisanthana T. A controlled trial of itraconazole to prevent relapse of Penicillium marneffei infection in patients infected with the human immunodeficiency virus.  N Engl J Med. 1998;  339 (24) 1739-1743

Worawit Louthrenoo, M.D. 

Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University

110 Intavaroros Road, Chiang Mai 50200, Thailand

Email: [email protected]