Viral Arthritis
Robert Goldfien, MD
Parvovirus B19
Virology
Small single-stranded DNA virus
Infects erythroid precursors in the bone marrow
B19 is the only member of the family known to infect humans
Parvovirus B19
Natural History
Experimental Infection
Viremia detectable 6-7 days after inoculation Clearing of viremia associated with appearance of IgM antibody Arthralgia, arthritis, rash after IgM response Incubation period reported from 6 to 28 days Infectious during viremic stage but not during antibody stage (when arthritis occurs)
Natural Infection
Parvovirus B19
Natural History
Clinical illness is biphasic:
Viremic stage
Asymptomatic in some patients Headache, malaise, pruritis, chills, fever Transient areticulocytosis
Antibody stage
Rash, arthralgia, arthritis and other manifestations
Parvovirus B19
Natural History
Parvovirus B19
Epidemiology
Prevalence of infection rises steadily after age 5 Adult prevalence ranges from 40%-80% Outbreaks most common in late winter to early summer Transmission is through oral and nasal secretions
Parvovirus B19
Arthritic Manifestations
Joint symptoms occur in 3%-8% of children, and 60%-80% of adults Onset of arthritis is acute affecting knees and hands in most patients Symptoms last more than 2 months in the majority of patients Joint erosions have not been described
Parvovirus B19
Relationship to RA
Initial presentation of parvovirus arthritis is rheumatoid-like However:
Erosive disease and rheumatoid nodules have not been seen Serological studies for parvovirus exposure in patients with RA have not shown evidence for a causative role
Alphavirus Arthritis
Mosquito-borne RNA viruses that cause epidemic arthritis, fever and rash May lead to arthritis through persistent infection of synovial macrophages Nearly all symptomatic adults have joint symptoms, usually polyarthralgia Symptoms usually resolve within 3-6 months Treatment with NSAIDs is generally effective
Alphavirus Arthritis
Specific Diseases and Distribution
Virus
Ch ikungunya
Clinical feature s
Ge ographic Distribu tion
Fever, rash, myalgia, arthralgia/arthritis, Africa, Ind ia, South East Asia, chronic arthralgia, haemorrhagic Ph ilippine Is lands symptoms, paraesthesias Fever, rash, myalgia arthralgia/arthritis, chronic arthralgia, haemorrhagic symptoms America (Trinidad, Surinam, Brazil, Co lombia, Bolivia)
Mayaro
O'nyon gnyong Barmah Forest Igbo Ora Ross River
Fever, rash, myalgia, arthralgia/arthritis, Africa (Ugan da, Kenya, Tanzan ia, chronic arthralgia, haemorrhagic Malawi, Senega l) symptoms, paraesthesias Fever, rash, myalgia, arthralgia/arthritis Fever, rash, myalgia, arthralgia Fever, rash, polyarthritis, chronic arthralgia, paraesthesias, glomerulonephritis Fever, rash, arthralgia/arthritis, paraesthesias Fever, rash, arthralgia/arthritis, chronic arthralgia, paraesthesias, Fever, rash, arthralgia/arthritis, chronic arthritis, Fever, rash, arthralgia Australia Ivory Coast Australia, Ne w Quinea, Fiji, The Solomon Is lands, American Samoa, South Pac ific islands Europe, Afr ica, Australia, Asia, Ph ilippines Sweden, Nor way Finland Russ ia
Sindbis Ocke lbo Pogosta Karelian fever
Hepatitis B
Joint symptoms mainly occur during the prodromal stage of infection 10%-25% of patients develop joint pain or arthritis May be migratory, symmetrical, or additive Persist for days to months Cases of persistent arthritis have been found in patients with chronic infection
Post-vaccination arthritis
No large prospective studies have been done Rubella and Hepatitis B vaccine associated with arthritis in post-vaccine period Risk of arthritis is 3-4 times higher in women Arthritis may be persistent Typical RA reported after hepatitis B vaccine, but causation not proven Hepatitis B vaccine safe in small study of RA patients