Rheumatology

Viral Arthritis

Does this patient have viral arthritis?

Viral arthritis is characterized by constitutional symptoms and joint pain with or without swelling. The joint complaints may occur at any time during the course of the infection, depending on the pathogen. Any non-specific features of fever, chills, and/or sweats in the context of joint complaints is highly suggestive of viral infection.

Occasionally, a unique feature is associated with a specific pathogen (Table I).

Table I.

What tests to perform?

Lab testing

  • Serologic tests may be ordered to help confirm the clinical suspicion of a specific virus. Demonstration of IgM antibodies with sequential conversion to IgG antibodies is commonly ordered when parvo B 19 is suspected. Sequential serologies may be ordered for other acute viral pathogens, but rarely are, unless thought necessary for making therapeutic decisions. Most arthritis associated acute viral illnesses are self limiting, and run their clinical course within several weeks to several months.

  • Chronic viral illnesses are typically diagnosed by demonstrating IgG serology against viral antigens, or by demonstrating the presence of a persistent antigen. This is frequently the case for Hepatitis C (IgG antibody by ELISA), HIV (Ig G antibody by ELISA) and hepatitis B (surface antigen).

  • If hepatitis C antibody or HIV antibody are demonstrated by ELISA, a confirmatory test is performed. These tests are often done reflexly by most laboratories, and will also be reflexly reported to the local health department for epidemiologic purposes.

  • Hepatitis C antibody positive serum is often reflexed to a recombinant immunoblot assay (RIBA) to confirm the result. However, hepatitis C PCR may be of more practical clinical value for confirmation of active viral infection, as it demonstrates the persistence of viral infection and reports the viral load. When this information is combined with a phenotype analysis, it's easier to identify patients likely to respond to interferon and ribavirin.

  • Positive PCR results strongly suggests the presence of live virus, that may act as an antigen. The viral antigen may bind with antibody to hepatitis C, forming an immune complex that may activate complement and deposit in local vasculature. Complement activation in the vasculature of specific organs may result in vasculitis and the clinical ramifications of arthritis, rash, and less commonly glomerulonephritis. Immune complexes can be identified by standard serologic techniques. These include the C1Q binding assay for immune complexes. The demonstration of high titer rheumatoid factor (RF) and cryoglobulins is also consistent with the presence of immune complexes. High titer RF and cryoglobulins are due to IgM antibodies to hepatitis C - which are very effective in forming large immune complexes.

  • Hepatitis B virus acts like an antigen in a similar way to the pathology outlined for hepatitis C.

  • Hepatitis B S Ag is present during acute hepatitis B infection, but also seen in chronic active hepatitis. During acute hepatitis B infection, the patient may complain of arthralgia or arthritis before becoming icteric. Urticaria and pruritis may accompany the joint complaints. If the patient clears the virus, the joint complaints fade. In chronic active hepatitis B, the virus does not clear and arthralgias (rarely arthritis) may persist. Clearance of the hepatitis B virus is demonstrated by the appearance and then disappearance of hepatitis B core antibody, and then the prolonged appearance of the hepatitis B surface antibody; which confers immunity against future hepatitis B infections.

  • Chronic hepatitis B infection is uncommonly associated with the development of polyarteritis nodosum, which often includes arthralgia and arthritis in its clinical presentation.

  • Acute HIV infection may be associated with arthritis or arthralgia, but is rarely diagnosed during the acute presentation. Chronic HIV may be associated with arthralgias and occasionally frankly inflammatory mono or oligoarthritis. Chronic HIV infection is screened for with an ELISA, testing for IgG antibodies to HIV. This is often confirmed with a Western blot assay.

  • Viral load may be may be determined by a PCR assay. The virus acts as an antigen with potential for immune complexes deposition into synovial vasculature, and subsequent joint related complaints.

  • The virus may become undetectable in patients treated with antiviral therapy for HIV. As a result, the patient my no longer be immune deficient. Patient with reconstituted immune systems may develop arthritis typically seen in autoimmune diseases, sarcoidosis or tuberculosis.

  • Rubella and rubella vaccination may result in a transient, and less commonly sustained viral arthritis/arthralgia. Native infection is commonly associated with a maculopapular rash. Serology or viral isolation from nasal pharyngeal swabs may confirm the diagnosis.

Imaging

Viral arthritis does not typically produce any characteristic radiologic signs. An effusion may be present. Erosions do not typically occur.

Biopsy

Analysis of synovial tissue is rarely performed to diagnose viral arthritis. Although viral conditions frequently infect synovial tissues, the self-limiting nature of most conditions and the availability of non-invasive testing makes these tests usually unnecessary.

Overall interpretation of test results (diagnosis, prognosis)

The diagnosis of most acute viral arthritides is an academic exercise as they are typically self-limiting illnesses. However, confirmation may prevent further unnecessary work-up and provide peace of mind to the patient and clinician. Some of the chronic viral arthritides are amenable to treatment - most notably HIV and hepatitis C. Testing in these instances is of great value. Likewise, it's important to identify acute hepatitis B infection as treatment may be helpful. Hepatitis B, C and HIV are also important to diagnose for epidemiologic reasons. Standard precautions may prevent spread of infection.

How should patients with viral arthritis be managed?

Treatable viruses should be managed in the usual fashion with antiviral and immune therapy as indicated for the specific virus. Viral load typically correlates with joint symptoms, and reducing viral load typically ameliorates joint symptoms as well as other features of immune complex deposition, like vasculitis.

What happens to patients with viral arthritis?

Untreated chronic infections may results in the persistence of arthritis/arthralgia and vasculitis. Most acute viruses are completely cleared and are self-limiting in terms of symptoms.

How to utilize team care?

For most self-limiting acute infections, consultations are not required. For chronic viral infections, infectious disease or hepatology consultation may be necessary. Rheumatology consultation may be needed if vasculitis is suspected.

Other considerations

  • Admission to the hospital is infrequently required and is based on the severity of clinical presentation; which in turn determines length of stay.

What is the evidence?

Calabrese, LH. "Emerging viral infections and arthritis: the role of the rheumatologist". Nat Clin Pract Rehumatol. vol. 1. 2008. pp. 2-3.

(This electronic publication addresses viral pathogens that could change the scene going forward)

Becker, J, Winthrop, KL. "Update of rheumatic manifestations of infectious diseases". Curr Opin Rheumatol. vol. 1. 2010. pp. 72-7.

(This recent update on pathogens (some emerging) addresses clinical presentation; identifying features and patterns)
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