# HIV-Associated Systemic Sclerosis: Literature Review and a Rare Case Report
## 3 Discussion  
The post-HAART era has witnessed a substantial diminution in the prevalence of rheumatic features with HIV infection. However, the emergence of another class of rheumatic disorders encompassing an array of systemic autoimmune and autoinflammatory disorders has gained immense concern and significance and resulted in a new clinical and therapeutic dilemma [19; 20; 21; 22; 23]. HIV-associated SSc is an infrequent occurrence, and only four case reports [16; 17; 5; 18] and two studies [24; 25] have delineated the association of HIV infection with SSc (Table 2). \begin{table}
\begin{tabular}{c c c c c c} \hline \hline
**S. No** & **Author(s) and Year** & **Age/Sex** & **HIV Status** & **Systemic Sclerosis Features** & \ \begin{tabular}{c} **Other Associated** \\ **Ailments** \\ \end{tabular}  \\ \hline \multirow{4}{*}{\(1\).} & [PERSON] et al., & & & The patient developed symptoms & \\  & 2005 [18] & CD4+ lymphocyte count & & of SSc in the background of & \\  & Simultaneous & 45/F & increase observed after & immune suppression and & - \\  & diagnosis of HIV & & 6 months HAART. & responded well to steroids and & \\  & and SSc & & & HAART therapy & \\ \hline \multirow{4}{*}{\(2\).} & [PERSON], et al., & & HIV +ve, CD4 cell & \begin{tabular}{c} Tumorification of forearms, thighs, \\ and legs; Raynaud’s \\ phenomena +ve; skin biopsy \\ revealed scleroderma features \\ \end{tabular}  & +ve HCV serology \\  & 2010 [17] & 44/M & & & \\  & &  
[PERSON] et al. (2005) evaluated the association of autoimmune disorders with HIV infection in an array of 32 published cases. Most of the cases exhibited de novo autoimmunity, while about 20% described the exacerbation of preceding disorders. The onset of these autoimmune diseases also exhibited significant variation, ranging from occurring briefly after induction of HAART to 27 months, with a mean of 9 months ([PERSON] et al., 2016). Cases reported by [PERSON] et al. (2016) and [PERSON] et al. (2018) demonstrated the simultaneous occurrence of HIV and SSc. However, our findings were in concurrence with the other case reports, which demonstrated that SSc was diagnosed after some time of evolution of the immunosuppression and/or the treatment of HIV ([PERSON] et al., 2016; [PERSON] et al., 2016). Our patient developed features of SSc after 5 years of antiretroviral therapy, most likely due to immune restoration syndrome. The precise pathogenesis of HIV-associated autoimmunity is still obscure. However, the role of retroviruses, HIV-evoked immune dysfunction causing an autoimmune state, molecular simulation between the viral protein and self-antigens (molecular mimicry), and autoimmune diseases depicting a type of IRIS are the various proposed etiopathogenic mechanisms. HIV infection and autoimmunity may also exist as separate ailments, and the onset of autoimmune disorders may be seen during HIV-evoked immune deficiency ([PERSON] et al., 2016). Few affirmative links have advocated the retroviral role in the etiopathogenesis of autoimmune disorders. However, large cohort studies are needed to establish the precise prevalence of autoimmune diseases with HIV ([PERSON] et al., 2016). The demonstration of retroviral conserved pol sequences in the sera of systemic sclerosis and mixed connective tissue disease patients (MCTD) may suggest the possible role of retroviruses in the pathogenesis of autoimmune diseases, thus advocating that these sequences may correspond with the onset of an autoimmune reaction to U1-70 kDa polypeptide ([PERSON] et al., 2016). Few studies have also exhibited SSc-like extracellular matrix protein production by normal human skin fibroblasts following retroviral protein expression ([PERSON] et al., 2016). Long-standing HIV infection results in a gradual diminution of humoral immunity owing to a consistent reduction in the CD4+ T-cell count.