# HIV-Associated Systemic Sclerosis: Literature Review and a Rare Case Report
## 1 Introduction  
Human immunodeficiency virus (HIV) was initially described in the year 1981. Since then, breakthrough advancements have taken place in the diagnostic and therapeutic protocols, thereby influencing the disease prognosis and prevalence [1]. Over the years, HIV infection has emerged as a universal public health menace. The 2018 statistics of the Joint United Nations Programme on HIV and AIDS (UNAIDS) reported approximately 37.9 million individuals living with HIV, with a 0.8% global HIV infection rate [2].  
Highly active antiretroviral therapy (HAART) has a favourable prognosis for people living with HIV/AIDS (PLWHA) by prolonging the life span. However, it may also induce the onset of other co-morbid states, including autoimmune diseases [3].  
HAART may act as a double-edged sword. It may diminish the autoimmune episode by restoring the dysregulated immune function [4]. It may also provoke the exacerbation of a latent autoimmune disorder or may trigger a new autoimmune disease's onset during the immune restoration inflammatory syndrome (IRIS), simulating a delayed hypersensitivity reaction to a foreign or self-antigen [4].  
The occurrence of rheumatologic ailments in HIV infection dates way back to the 1980s, and the array of rheumatic conditions (artharalgia, arthritis, myalgia, and myositis) have evolved significantly in the post-HAART period. However, autoimmune connective tissue diseases (such as Sjogren's syndrome, systemic lupus erythematosusus, dermatomyositis, and systemic sclerosis) have infrequently been documented with HIV [5].  
The coexistence of autoimmune and inflammatory diseases despite an apparent loss of immunocompetent caused by HIV infection is quite ambiguous [6]. Hence, such cases need to be reported to delineate the complex pathogenic mechanisms involved in HIV-associated autoimmunity. Whether the autoimmune diseases occurred due to HIV itself, HIV-related dysregulated immune system, or molecular simulation between the HIV and self-antigen needs to be further explored.  
Systemic sclerosis (SSc) is a rare entity affecting less than 10 per 100,000 individuals annually in both Europe and North America [7]. Patients often complain of dry mouth due to salivary gland fibrosis. Dry-mouth symptoms may predispose to an increased incidence of candida infections and high caries rates [8; 9]. Dysphagia and dysphonia may be seen due to tongue stiffness and limited mobility, along with decreased flexibility of the oral mucosa and soft palate [10]. Tooth erosion and dental caries may be seen in cases of patients with oesophageal dysmotility, probably due to the gastroesophageal reflux effect [11]. Fibrous adhesions in the articulating surfaces of the temporomandibular joint may result in pseudoankylosis [9]. Aberrant mandibular movements and subluxation are the other likely dental features. Advanced vascular fibrosis and delayed wound healing pose a challenge to surgical treatment [12]. Periodontal features include a low gingival bleeding index, increased periodontal pocket depth, higher periodontal attachment loss, and multiple foci of gingival recession [13].  
Infrequently, SSc may be associated with idiopathic tooth resorption. Extreme resorption may result in painful trigeminal neuropathy (TN) due to compression of the inferior alveolar nerve [14]. These patients are more vulnerable to developing orophyangeal and tongue carcinoma; hence, these patients should be subjected to a detailed and periodic oral cancer screening, even in cases with a restricted oral opening (e.g., by using an endoscope) [15].  
An extensive literature search carried out on the Google Scholar and PubMed search engines revealed only four case reports of HIV-associated SSc [5; 16; 17; 18]. To the best of our knowledge, ours is the fifth reported case. Hereby, we report a rare case of HIV-associated SSc in a 44-year-old female who reported mild pain in the mandibular posterior teeth region and responded well to the prescribed treatment.