Viral Arthritis Clinical Presentation

Viral arthritis occurs during the viral prodrome, when the characteristic rash develops. In the United States, patients with the most common viral arthritides generally present with symmetrical small-joint involvement, though different patterns of joint and soft-tissue involvement occur with different viral infections. Many of the viruses that can cause arthritis have specific geographic niches (eg, HTLV-1 in Japan and the Caribbean), so a travel history will be important in some cases.

 

Physical findings in patients with viral arthritis vary substantially, depending on the type of virus causing the arthritis.

Parvovirus B19

Clinical features of arthritis associated with parvovirus B19 infection in children include the following:

• As many as 70% of patients are asymptomatic
• A few may have flulike symptoms (eg, fever, headache, sore throat, cough, anorexia, vomiting, diarrhea, or arthralgia)
• A bright red rash is typically noted, often characterized as having a “slapped-cheek” appearance (see the images below)
• Joint symptoms are rare (5-10%)
• Viral arthritis. Typical "slapped cheek" appearance. Courtesy of Brenda Moroz, MD, Montreal Children's Hospital.

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  Viral arthritis. "Slapped cheeks" with typical reticulated erythema of arms. Courtesy of Brenda Moroz, MD, Montreal Children's Hospital.

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Clinical features in adults include the following:

• Rash is rare

• Joint symptoms occur in as many as 60% of patients, with arthralgia noted more commonly than frank arthritis; arthralgia is usually self-limited and symmetrical and is noted in peripheral small joints, hands (ie, proximal interphalangeal and metacarpophalangeal joints), wrists, knees, and ankle joints, in association with prominent morning stiffness and swelling

• Several diseases may arise as a consequence of parvovirus B19 infection, such as erythema infectiosum (fifth disease), transient aplastic crisis (especially in patients with sickle cell disease, thalassemia, or HIV-induced anemia), and fetal hydrops in infected mothers

Rare clinical features include the following:

• Henoch-Schönlein purpura is rare but possible ^[13]
• Thrombotic thrombocytopenic purpura is unlikely but may be present
• Polyarteritis nodosa is rare
• Granulomatosis with polyangiitis (Wegener granulomatosis) is possible but rare

Hepatitis viruses

Clinical features of arthritis related to hepatitis B virus (HBV) infection include the following:

• Symmetric arthritis may be migratory or additive; with the hand and knee joints most commonly affected; significant morning stiffness and fusiform swelling are associated with HBV-induced arthritis

• Arthritis and urticaria may precede jaundice by days to weeks and may persist for several weeks after jaundice resolves

• Recurrent polyarthralgia or polyarthritis can occur in patients with chronic active hepatitis or chronic HBV viremia

• Polyarteritis nodosa may be associated with chronic HBV viremia

• Patients may have arthritis-dermatitis syndrome

• Nephropathy has been described

• Systemic necrotizing vasculitis is also a clinical feature

Clinical features of arthritis related to hepatitis C virus [HCV] infection include the following:

• A rapidly progressive acute arthralgia (but rarely arthritis) typically occurs in a rheumatoid distribution, affecting the hands, wrists, shoulders, knees, and hips

• Myalgia is common

• Essential mixed cryoglobulinemia (a triad of arthritis, palpable purpura, and cryoglobulinemia) is associated with HCV in most cases

• Necrotizing vasculitis with cryoglobulinemia is a clinical feature

• Essential mixed cryoglobulinemia type II or III is associated with more severe skin disease, such as Raynaud phenomenon, purpura, livedo reticularis, distal ulcers, gangrene, and peripheral neuropathy

• Sjögren syndrome has been described in numerous patients with HCV infection

• An association may exist between HCV infection and fibromyalgia

Rubella virus

Clinical features of arthritis associated with rubella virus infection (in both children and adults) include the following:

• Low-grade fever, malaise, and coryza are typical

• Rash (acute mild-to-severe viral exanthema [maculopapular rash]) appears first on the face, then the trunk and upper extremities, and finally on the lower extremities, sparing the palms and soles

• Significant lymphadenopathy (posterior cervical, postauricular, and occipital) may be noted

• Arthritis is usually sudden in onset, appearing 1 week before or after the rash; morning stiffness is symmetric and polyarticular in distribution (eg, fingers, knees, and wrists), brief in duration (lasting a few days to weeks), and without residua

• Arthritis similar to that occurring with natural infection may also develop within a few weeks of vaccination by attenuated rubella virus; the HPV77/DK12 strain is the most arthritogenic of the vaccine strains available in the United States; the currently used RA27/3 strain causes postvaccination joint symptoms in about 15% of recipients

In children, the following 2 syndromes may occur with either natural infection or vaccination:

• Arm syndrome – A brachial radiculoneuritis causes arm and hand pain and dysesthesias that worsen at night

• Catcher’s crouch syndrome – A lumbar radiculoneuropathy causes popliteal fossa pain when the child arises in the morning

Both syndromes occur 1-2 months after vaccination. The first episode may last up to 2 months, but recurrence is usually shorter in duration. Catcher’s crouch syndrome may recur for up to a year but causes no permanent damage.

Alphaviruses

Clinical features of arthritis associated with alphavirus infection include the following:

• Fever has been reported, with temperatures of 102.2-104°F (39-40°C)

• Arthritis or a migratory polyarthralgia of the small joints of the hands, wrists, elbows, knees, feet, and ankles occurs, along with stiffness and swelling; the arthritis is generally symmetric and polyarticular; in most alphavirus infections, joint symptoms resolve over 3-7 days, but they can persist for more than a year, albeit with no evidence of permanent joint damage

• Maculopapular rash may be itchy to some patients