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High Prevalence of Osteonecrosis of the Femoral Head in HIV-Infected Adults
Reported by Jules Levin
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This is an official publication of data that had been reported previously at
science conferences. The authors report a high rate of symptomless
osteonecrosis as measured by MRI in HIV+ persons. But the authors conclude
they cannot determine if this high rate is due to HIV or by some of the drugs
taken and intense bodybuilding exercises performed by some of the study
participants who had HIV infection. Osteonecrosis was more frequent among the
HIV-infected persons who had used steroids, lipid-lowering drugs, or
testosterone and among those who routinely did bodybuilding exercises. None
of the adults without HIV infection were found to have osteonecrosis.
Although this study did not involve patients with hip pain, osteonecrosis
should probably be considered in HIV-infected persons who begin to have pain
and problems with their hips.
Kirk D. Miller, MD; Henry Masur, MD; Elizabeth C. Jones, MD, MPH; Galen O.
Joe, MD;
Margaret E. Rick, MD; Grace G. Kelly, MSS; JoAnn M. Mican, MD; Shuying Liu,
BSN;
Lynn H. Gerber, MD; William C. Blackwelder, PhD; Judith Falloon, MD; Richard
T. Davey, MD; Michael A. Polis, MD, MPH; Robert E. Walker, MD; H. Clifford
Lane, MD; and Joseph A. Kovacs, MD
Ann Intern Med. 2002;137:17-25.
Osteonecrosis has been reported to occur occasionally among HIV-infected
patients. The diagnosis of symptomatic osteonecrosis of the hip in two of the
authors' patients, together with reports from community physicians, raised a
concern that the prevalence of osteonecrosis is increasing.
THis study was done to determine the prevalence of osteonecrosis of the hip
in asymptomatic
HIV-infected patients and to identify potential risk factors associated with
osteonecrosis.
This study is s survey and comparison study conducted at the Clinical Center
of the U.S. National Institutes of Health.
339 asymptomatic HIV-infected adults (of 364 asked to participate) and 118
age- and sex-matched HIV-negative volunteers enrolled between 1 June and 15
December 1999.
Osteonecrosis of the hip was measured, as documented by magnetic resonance
imaging. Data from clinic records and a patient questionnaire administered
before
magnetic resonance imaging were used in an analysis of risk factors. A subset
of
patients was evaluated for hypercoagulable state.
Fifteen (4.4% [95% CI, 2.5% to 7.2%]) of 339 HIV-infected participants had
osteonecrosis lesions on magnetic resonance imaging, and no HIV-negative
participants had similar lesions. Among HIV-infected participants,
osteonecrosis occurred more frequently in those who used systemic
corticosteroids, lipid-lowering agents, or testosterone; those who exercised
routinely by bodybuilding; and those who had detectable levels of
anticardiolipin antibodies.
The authors concluded that patients infected with HIV have an unexpectedly
high occurrence of osteonecrosis of the hip. Although screening asymptomatic
patients is not warranted,
HIV-infected patients with persistent groin or hip pain should be evaluated
for this debilitating complication.
Problems of the Hip Bone in Patients with HIV Infection
What is the problem and what is known about it so far?
HIV is the virus that causes AIDS. Since the mid 1990s, several powerful
therapies
(combinations of antiretroviral drugs) have helped increase length of life in
many people
with HIV infection. The focus of care for patients with HIV infection has
shifted to
managing long-term complications and complex drug regimens and their side
effects.
Recently, doctors have noted that some patients with HIV infection have a
problem with
the bone in their hip, in which part of the bone dies (osteonecrosis of the
hip). The
condition can become painful and disabling. In some instances, surgery for a
total hip
replacement is needed. Osteonecrosis of the hip doesn't occur very often in
adults with
normal immune systems. Its frequency in people with HIV infection is not
known.
Why did the researchers do this particular study?
To see whether osteonecrosis of the hip occurs frequently in people with HIV
infection.
Who was studied?
339 adults with HIV infection and 118 adults without HIV infection. None of
the
participants had hip pain or hip symptoms.
How was the study done?
Patients with HIV infection who were enrolled in special studies at the
National Institutes
of Health (NIH) were invited to have a magnetic resonance imaging (MRI) scan
of the hip
bone. This is a scan that uses radio waves and a magnetic field to produce
detailed
pictures of the bone. The researchers also invited "normal volunteers"
without HIV
infection or other conditions to have the scan. Radiologists who did not know
whether
the scans were from a person with HIV infection interpreted the scan results.
What did the researchers find?
Fifteen (4.4%) of the adults with HIV infection had osteonecrosis of the hip
detected by
MRI scan. Osteonecrosis was more frequent among the HIV-infected persons who
had
used steroids, lipid-lowering drugs, or testosterone and among those who
routinely did
bodybuilding exercises. None of the adults without HIV infection were found
to have
osteonecrosis.
What were the limitations of the study?
The adults in this study had no symptoms. We do not know whether the
osteonecrosis
that was detected by MRI scans would have eventually caused hip pain or other
problems. Also, we cannot tell whether the osteonecrosis was caused by
something
specific to HIV infection or by some of the drugs taken and intense
bodybuilding
exercises performed by some of the study participants who had HIV infection.
What are the implications of the study?
Asymptomatic patients with HIV infection have an unexpectedly high occurrence
of
osteonecrosis of the hip detected by MRI scan. Although this study did not
involve
patients with hip pain, osteonecrosis should probably be considered in
HIV-infected
persons who begin to have pain and problems with their hips.
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