Viral arthritis is inflammation of the joints from a viral infection. Viral arthritis is less common than bacterial arthritis and often the diagnosis is made in a lesser number of patients because of because of the late presentation of this condition.
Most of these arthritides of viral origin require only symptomatic treatment. In some cases, antiviral treatment is given for the underlying systemic disease.
Viral arthritis occurs worldwide but the geographical prevalence of the viruses may vary.
Depending on the type of virus involved, viral arthritis could be found more in children or adults.
For example, parvovirus B19 affects children more than adults.
No gender variation has been seen for HBV or HCV
Viruses Causing Arthritis
- 12% of cases
- Occur in adults frequently exposed to children
- Spread by respiratory secretions or blood products
- Occurs more in winters
Hepatitis viruses [A, B, and C]
- HAV – 10-14% of cases of viral arthritis, orofecal route
- HBV – 20-25% of cases
- HBV and HCV have a parenteral or sexual route
- Mainly women are affected
- Transmission by nasopharyngeal secretions
- Late winter and spring.
- All mosquito-borne
- Chikungunya virus
- O’nyong-nyong virus
- Ross River virus
- Mayaro virus
- Sindbis virus
- Barmah Forest virus
- Geographic distributions vary with each virus
- HIV- can cause arthralgia, arthritis, reactive arthritis, psoriatic arthritis
- Human T-cell lymphotropic virus – 1
- Spreads through ingestion of breast milk, sexual intercourse, and use of blood products.
- Usually polyarthralgia but may cause arthritis
Adenovirus or coxsackieviruses A9, B2, B3, B4, and B6
- Cause polyarthritis, pleuritis, myocarditis
Viral infection is dependent on the host as well virus causing it.
Different viruses show a predilection for different ages, sex or genetics.
Involvement of the joint could be due to deposition of immune complexes in the synovium. Molecular mimicry leads to abnormal self-reactivity by alteration of immune tolerance.
HIV and HTLV1 may cause immunodeficiency and thus lead to opportunistic infection.
Presentation of Viral Arthritis
Viral arthritis involves joints symmetrically. Usually, the peripheral joint like hands, wrists, elbows, and knees may be affected. Affected joints swell and become stiff especially in the morning. Joint and soft-tissue involvement occur with different viral infections.
Viral arthritis is not destructive in nature. Physical findings in patients with viral arthritis vary with the type of virus causing arthritis.
Other features particular to viral illness may be present depending on the viruses.
- Parvovirus B19 infection have typical flu-like symptoms and bright red rash [slapped cheek appearance] in children but in adults, the rash is rare. Joint symptoms are less common in children but in adults, they are seen in 60% of patients.
- Hepatitis viruses infect liver and lead to jaundice.
- Cryoglobulinemia is associated with HCV in most cases
- Rubella virus has maculopapular rash on the face, trunk and upper extremities. Arthritis is sudden and appear 1 week before or after the rash
- Alphaviruses have typical geographical distribution and are associated with high fever with or without maculopapular rash
- Rheumatic Fever
- Psoriatic Arthritis
- Rheumatoid Arthritis
- Sjogren Syndrome
- Systemic Lupus Erythematosus (SLE)
- Seronegative Spondyloarthropathy
- Lyme Disease
- Complete blood count
- Virus specific antibody/antigen titre
- Immunoglobulin M in parvovirus
- IgM-specific anti-HAV
- Serum hepatitis B surface antigen
- Anti-HCV, HCV-RNA by PCR
- Anti–rubella virus IgM, IgG
- In HIV – detection of CD8+T cells and P-24 antigen in synovial fluid
- Liver function tests
Most of the virus-associated joint infection do not show erosive changes except in seronegative or psoriatic-type arthropathy.
Aspiration of the joint is useful to help rule out other conditions, such as crystal arthropathy or bacterial infection.
Treatment of Viral Arthritis
Viral arthritis is mild and requires only symptomatic treatment. NSAIDs, low dose steroids are mostly used. Antiviral drugs are used when indicated.
Antibiotics may be prescribed in selected patients where there is a secondary bacterial infection or prophylaxis in patients where there is an immunodeficiency.
Immunoglobulins can be used to enhance the immunity.
Surgical drainage is not indicated unless septic arthritis is considered likely. Gentle mobilization may be initiated after a few days of rest.
In large joints, patients with coexisting inflammatory arthropathy, diabetes mellitus, and infection with virulent organisms such as staph aureus more than one drainage surgery may be needed.
In hepatitis C virus infection, interferon alfa-2b is given in a dosage of 3-5 million U 2-3 times a week for 6 months.
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