eMedicine Specialties > Rheumatology > Infectious Arthritis
Viral Arthritis: Treatment & Medication
Updated: Aug 1, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
In general, viral arthritis is mild requires only symptomatic treatment with analgesics or nonsteroidal anti-inflammatory drugs (NSAIDs). Occasionally, a brief course of low-dose prednisone is used.
- Parvovirus B19: Treatment is symptomatic with analgesics and NSAIDs. In severe cases, aspiration of fluid from the affected joint may relieve pain.
- Hepatitis A virus: Treatment is symptomatic with analgesics and NSAIDs. Prophylaxis for contacts is an important element of management.
- Hepatitis B virus: No evidence indicates that early therapy for acute HBV infection with interferon alfa or antiviral agents decreases the rate of chronicity or speeds recovery. Most patients with acute icteric HBV infection recover without residual injury or chronic hepatitis. Focus management of acute HBV infection on avoidance of further hepatic injury and prophylaxis of contacts.
- Hepatitis C virus: Administer interferon alfa-2b (3-5 million U 2-3 times/wk for 6 mo). Combination therapy with ribavirin (1000-1200 mg/d) is recommended and has been shown to yield better response rates. Patients with complications of cryoglobulinemia are best treated with antiviral therapy. However, corticosteroids and cyclophosphamide may be initially required in patients with more active, severe vasculitic complications.
- Rubella virus: Treatment is symptomatic with analgesics and NSAIDs. Some investigators have recommended steroids at low-to-moderate doses to control symptoms and viremia.
- Alphaviruses: Treatment is symptomatic with analgesics and NSAIDs, but avoid aspirin in order to prevent a hemorrhagic component with alphavirus rashes. Chloroquine phosphate (250 mg/d) has been used when NSAIDs are not effective.
- Human immunodeficiency virus
- Use a combination of newer antiretroviral therapy.
- Treatment is symptomatic with analgesics and NSAIDs.
- Administer sulfasalazine and methotrexate in patients with conditions refractory to NSAID therapy.
- Prednisone, antimalarials, and other agents have been used successfully in patients with polymyositis, reactive arthritis, Sjögrenlike syndrome, psoriatic arthritis, and vasculitis.
- Antiretroviral and prophylactic therapy, sulfamethoxazole-trimethoprim, and pentamidine help improve associated rheumatic symptoms.
- Intravenous immune globulin, interleukin-12, interleukin-2, interferon-gamma, and/or sargramostim may be effective in some patients infected with HIV who have arthritis.
- Human T-lymphotropic virus 1: Treatment options are poor.
Surgical Care
Surgical drainage is not indicated unless septic arthritis is considered likely.
Consultations
In general, patients can initially be seen by their family doctors. In patients who do not improve or in whom the treatment response is poor, the following practitioners may be consulted:
- Rheumatologists
- Hepatologists (if HBV or HCV infection is considered)
- Infectious disease specialists
- Immunologists
Diet
No restrictions are necessary.
Activity
Recommend gentle mobilization after a few days of rest.
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Nonsteroidal anti-inflammatory drugs
The agents have analgesic, anti-inflammatory, and antipyretic activities. Their mechanisms of action are unknown, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may be present, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.
Naproxen (Anaprox, Naprelan, Aleve, Naprosyn)
Used for relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which is responsible for prostaglandin synthesis
Adult
250-500 mg PO bid; may increase to 1.5 g/d for limited periods
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation
Antimalarial agents
These derivatives of 4-aminoquinoline are active against various autoimmune disorders.
Hydroxychloroquine (Plaquenil)
Inhibits chemotaxis of eosinophils and locomotion of neutrophils and impairs complement-dependent antigen-antibody reactions. Hydroxychloroquine sulfate 200 mg is equivalent to 155 mg hydroxychloroquine base and 250 mg chloroquine phosphate.
Adult
400 mg PO qd or 200 mg bid for several wk depending on response
Prolonged therapy: 200-400 mg/d
Pediatric
3-5 mg base/kg/d PO qd or divided bid; not to exceed 7 mg/kg/d
Serum levels increase with cimetidine; magnesium trisilicate may decrease absorption
Documented hypersensitivity to 4-aminoquinoline derivatives; psoriasis; retinal and visual-field changes attributable to 4-aminoquinolines
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hepatic disease, G-6-PD deficiency, psoriasis, and porphyria; not recommended for long-term use in children; perform periodic (q6mo) ophthalmologic examinations; test periodically for muscle weakness
Immunoglobulin agents
These agents are used to improve clinical and immunologic aspects of the disease. They may decrease autoantibody production and increase solubilization and removal of immune complexes.
Immune globulin, intravenous (Gammar-P, Sandoglobulin, Gammagard)
Neutralizes circulating myelin antibodies through antiidiotypic antibodies; down-regulates proinflammatory cytokines, including INF-gamma; blocks Fc receptors on macrophages; suppresses inducer T and B cells and augments suppressor T cells; blocks complement cascade; promotes remyelination; may increase CSF IgG (10%).
Adult
2 g/kg IV over 2-5 d
Pediatric
Not established
Globulin preparation may interfere with immune response to live virus vaccine (MMR) and reduce efficacy (do not administer within 3 mo of vaccine)
Documented hypersensitivity; IgA deficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Check serum IgA before IVIG (use an IgA-depleted product, eg, Gammagard S/D); infusions may increase serum viscosity and thromboembolic events; infusions may increase risk of migraine attacks, aseptic meningitis (10%), urticaria, pruritus, or petechiae (2-30 d postinfusion); increases risk of renal tubular necrosis in elderly patients and in patients with diabetes, volume depletion, and preexisting kidney disease; laboratory result changes associated with infusions include elevated antiviral or antibacterial antibody titers for 1 mo, 6-fold increase in ESR for 2-3 wk, and apparent hyponatremia
Interferons
These are naturally produced proteins with antiviral, antitumoral, and immunomodulatory actions. Alfa-, beta-, and gamma-interferons may be given topically, systemically, and intralesionally.
Interferon alfa-2b (Intron A)
Protein product manufactured by recombinant DNA technology. Mechanism of antitumor activity is not clearly understood; however, direct antiproliferative effects against malignant cells and modulation of host immune response may play important roles.
Adult
5 million U/d or 10 million U 3 times/wk IM/SC for 16 wk; reduce dose by 50% if severe reactions occur or temporarily discontinue therapy until symptoms from adverse reactions improve
Pediatric
Not established
Potential risk of renal failure when administered concurrently with IL-2; theophylline may increase toxicity by reducing clearance; cimetidine may increase antitumor effects; zidovudine and vinblastine may increase toxicity
Documented hypersensitivity; patients who have anaphylactic sensitivity to mouse IgG, egg protein, or neomycin; autoimmune hepatitis
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Depression and suicidal ideation may be adverse effects of treatment; infrequently, severe or fatal GI hemorrhage reported in association with interferon alfa therapy; prior to initiation of therapy, perform tests to quantitate peripheral blood hemoglobin, platelets, granulocytes, hairy cells, and bone marrow hairy cells; monitor periodically (eg, qmo) during treatment to determine response to treatment; if patient does not respond within 6 mo, discontinue treatment; if response occurs, continue treatment until no further improvement observed; not known whether continued treatment is beneficial
Corticosteroid agents
These agents have anti-inflammatory properties and cause profound and varied metabolic effects. They modify the body's immune response to diverse stimuli.
Prednisone (Meticorten, Sterapred, Deltasone)
Immunosuppressant for treatment of autoimmune disorders; may decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. Stabilizes lysosomal membranes and suppresses lymphocyte and antibody production.
Adult
5-60 mg/d PO qd or divided bid/qid; taper over 2 wk as symptoms resolve
Pediatric
4-5 mg/m2/d PO; alternatively, 0.05-2 mg/kg PO divided bid/qid; taper over 2 wk as symptoms resolve
Coadministration with estrogens may decrease clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; viral infection, peptic ulcer disease, hepatic dysfunction, connective tissue infections, and fungal or tubercular skin infections; GI bleeding or ulceration
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use
Antineoplastic agents
These agents inhibit key factors responsible for deregulated cell proliferation.
Cyclophosphamide (Neosar, Cytoxan)
Alkylating agent that depresses T- and B-cell function.
Adult
Nonmalignant disease: 2.5-3 mg/kg/d PO divided qid
Lupus: 500-750 mg/m2 IV qmo
Pediatric
Administer as in adults
Allopurinol may increase risk of bleeding or infection and enhance myelosuppressive effects; may potentiate doxorubicin-induced cardiotoxicity; may reduce digoxin serum levels and antimicrobial effects of quinolones; toxicity may increase with chloramphenicol; may increase effect of anticoagulants; coadministration with high doses of phenobarbital may increase leukopenic activity; thiazide diuretics may prolong cyclophosphamide-induced leukopenia; coadministration with succinylcholine may increase neuromuscular blockade by inhibiting cholinesterase activity
Documented hypersensitivity; severely depressed bone marrow function
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Regularly examine hematologic profile (particularly neutrophils and platelets) to monitor for hematopoietic suppression; regularly examine urine for RBCs, which may precede hemorrhagic cystitis
Methotrexate (Folex PFS, Rheumatrex)
Unknown mechanism of action in treatment of inflammatory reactions; may affect immune function. Ameliorates symptoms of inflammation (eg, pain, swelling, stiffness). Adjust dose gradually to attain satisfactory response.
Adult
7.5-25 mg PO/IM once weekly
Pediatric
5-15 mg/m2/wk PO/IM as single dose or 3 divided doses 12 h apart
Oral aminoglycosides may decrease absorption and blood levels of concurrent oral MTX; charcoal lowers levels; coadministration with etretinate may increase hepatotoxicity; folic acid or its derivatives contained in some vitamins may decrease response; probenecid, NSAIDs, salicylates, procarbazine, and sulfonamides (including TMP-SMZ) can increase plasma levels; may decrease phenytoin plasma levels; may increase plasma levels of thiopurines
Documented hypersensitivity; alcoholism; hepatic insufficiency; documented immunodeficiency syndromes; preexisting blood dyscrasias (eg, bone marrow hypoplasia, leukopenia, thrombocytopenia, significant anemia); renal insufficiency
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Monitor CBC counts qmo and liver and renal function q1-3mo during therapy (monitor more frequently during initial dosing, dose adjustments, or when risk of elevated levels, eg, dehydration); has toxic effects on hematologic, renal, GI, pulmonary, and neurologic systems; discontinue if significant drop in blood counts occurs; fatal reactions reported when administered concurrently with NSAIDs
Anti-inflammatory agents
These agents inhibit key factors responsible for inflammation.
Sulfasalazine (Azulfidine, EN-tabs)
Useful in the management of ulcerative colitis and acts locally in colon to decrease the inflammatory response. Systemically inhibits prostaglandin synthesis.
Adult
1-3 g/d PO g/d in divided doses
Pediatric
<2 years: Not established
>2 years: 40-60 mg/kg/d PO in 3-6 divided doses; follow by maintenance dose of 20-30 mg/kg/d divided qid
Decreases effects of iron, digoxin, and folic acid; conversely, increases effect of oral anticoagulants, oral hypoglycemic agents, and MTX
Documented hypersensitivity; sulfa drugs or any component; GI or GU obstruction
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in patients with renal or hepatic impairment, blood dyscrasias, or urinary obstruction
Analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who experience pain.
Acetaminophen (Aspirin-Free Anacin, FeverAll, Tempra, Tylenol)
DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.
Adult
325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses in 24 h
Rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity; known G-6-PD deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible in persons with chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; contained in many OTC products and combined use with these products may result in cumulative doses exceeding recommended maximum dose
Antiviral agents
Nucleoside analogs are initially phosphorylated by viral thymidine kinase to eventually form a nucleoside triphosphate. These molecules inhibit HSV polymerase with 30-50 times the potency of human alpha-DNA polymerase.
Ribavirin (Rebetol, Virazole, Rebetron)
Indicated for chronic HCV infection. Inhibits replication of RNA and DNA viruses. Additionally, inhibits initiation and elongation of RNA fragments, resulting in inhibition of viral protein synthesis.
Adult
<75 kg: 2 X 200-mg cap AM and 3 X 200-mg cap PM PO qd for 24-48 wk
>75 kg: 3 X 200-mg cap AM and 3 X 200-mg cap PM PO qd for 24-48 wk
Pediatric
Not established
Coadministration with antacids containing magnesium, aluminum, and simethicone may decrease ribavirin AUC (clinical relevance unknown)
Documented hypersensitivity; patients with hemoglobinopathies (eg, thalassemia major, sickle cell anemia); patients with CrCl <50 mL/min; women who are pregnant or men whose female partners are pregnant
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Monotherapy not effective for treatment of chronic HCV infection (ribavirin caps must not be used alone); safety and efficacy of ribavirin caps only established when used together with interferon alfa-2b recombinant (Intron A) as Rebetron combination therapy; suspend therapy in patients with signs and symptoms of pancreatitis and discontinue in patients with confirmed pancreatitis; perform CBC and differential WBC counts, platelet count, liver function, TSH, and pregnancy tests before beginning treatment and periodically thereafter
Antibiotics
Therapy must cover all likely pathogens in the context of this clinical setting. Indications include Pneumocystis carinii pneumonia and HCV infection.
Pentamidine (Pentacarinat, Pentam-300, NebuPent)
Inhibits growth of protozoa by blocking oxidative phosphorylation and inhibiting incorporation of nucleic acids into RNA and DNA, causing inhibition of protein and phospholipid synthesis.
Adult
4 mg/kg/d IV/IM qd for 10-14 d
Pediatric
Administer as in adults
Coadministration with cidofovir increases risk of nephrotoxicity; concomitant use of foscarnet may decrease serum calcium levels; risk of pancreatitis with zalcitabine may be additive; coadministration with other drugs that prolong QT interval (eg, dofetilide) increases risk
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in diabetes mellitus, hypertension or hypotension, hepatic dysfunction, hypoglycemia, leukopenia, and thrombocytopenia
Sulfamethoxazole and trimethoprim (Septra, Cotrim, Bactrim)
Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Antibacterial activity of TMP-SMZ includes common urinary tract pathogens, except Pseudomonas aeruginosa.
Adult
160 mg TMP/800 mg SMZ PO q12h for 10-14 d
Pediatric
<2 months: Do not administer
>2 months: 10-20 mg TMP/kg/d PO/IV divided tid/qid for 14 d
May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly; phenytoin levels may increase with coadministration; may potentiate effects of MTX in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Documented hypersensitivity; megaloblastic anemia due to folate deficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBC counts frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, administer 5-15 mg/d leucovorin); caution in folate deficiency (eg, persons with chronic alcoholism, elderly persons, those receiving anticonvulsant therapy, or those with malabsorption syndrome); hemolysis may occur in persons with G-6-PD deficiency; AIDS patients may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); administer fluids to prevent crystalluria and stone formation
More on Viral Arthritis |
| Overview: Viral Arthritis |
| Differential Diagnoses & Workup: Viral Arthritis |
 Treatment & Medication: Viral Arthritis |
| Follow-up: Viral Arthritis |
| Multimedia: Viral Arthritis |
| References |
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Further Reading
Keywords
viral arthritis, viral-induced arthritis, virus-induced arthritis, arthritis, chronic arthralgia, rheumatoid arthritis, RA, polyarticular arthritis, rheumatic disease, rheumatoid arthritis, hepatitis B virus, HBV, hepatitis C virus, HCV, hepatitis, parvovirus B19, B19 virus, parvovirus B-19, alphaviruses, alpha virus, alphavirus, retroviruses, retrovirus, rubella virus, Rubivirus, HIV, HIV-1, human T-lymphotropic virus 1, HTLV-1, Epstein-Barr virus, EBV, human immunodeficiency virus type 1, human immunodeficiency virus, HIV infection, HIV disease, erythema infectiosum, fifth disease
