Viral arthritis

Viral arthritis is a joint lesion in various viral infections. Clinical manifestations include arthralgic syndrome, local swelling and movement difficulties. Joint stiffness resembling rheumatoid arthritis is possible. The diagnosis is based on the symptoms and laboratory signs of a particular viral infection. Treatment in most patients is limited to symptomatic therapy with the use of nonsteroidal anti-inflammatory drugs or treatment of the underlying disease. Sometimes arthritis of viral genesis goes away on its own without any medical intervention.

General information
Viral arthritis (VA) is an inflammation of the joints that occurs as one of the manifestations of a viral infection. The frequency of articular syndrome development, as well as sexual dimorphism and age differences are individual for each viral pathology. For example, VA in viral hepatitis A develops in adults 5 times more often than in children, and occurs in 10% of all infected. Arthritis in mumps mainly affects adult men (the ratio with women is 7:1). On the contrary, women are more susceptible to infectious arthritis with rubella (30% and 6%, respectively). Joint inflammation occurs in about 3% of patients with HIV infection.

Reasons
Currently, about 30 viruses are known that can cause viral arthritis. The most common pathogens include parvovirus 19, rubella virus, hepatitis B and C. Less often, the etiological factor is hepatitis A and HIV alphaviruses. Some vaccines, for example, live rubella vaccine, can provoke joint syndrome. Repeated infection increases the risk of joint inflammation several times, therefore, the overwhelming number of arthritis of viral etiology occurs in adults.

There is a genetic predisposition to arthritis in alphavirus infections. Patients were found to carry HLA-DR7. Infection with parvovirus B19 and rubella virus is carried out by airborne droplets, hepatitis A – by eating unwashed vegetables and fruits, drinking unboiled water. Hepatitis B, C, HIV infection are transmitted parenterally (unprotected sexual intercourse, the use of common syringes, non-disinfected surgical instruments).

Pathogenesis
The mechanism of development of inflammatory processes in the joint is different and depends on the infectious agent. Viruses such as HIV and rubella virus have a tropicity to joint tissue and are capable of replication in synovial membrane cells, while others (for example, alphaviruses) produce specific arthritic toxins. Hepatitis B virus antigens with antibodies form immune complexes that settle on the synovial membrane, provoking an inflammatory reaction. Hepatitis C virus and parvovirus B19 synthesize antibodies (rheumatoid factor, antinuclear factor) involved in autoimmune reactions and attacking joint tissues.

Symptoms of viral arthritis
In general, the clinic of various etiological forms of arthritis is similar. The main differences are observed in the general (extra-articular) symptoms of a specific viral infection – rashes on the skin, heaviness in the right hypochondrium, jaundice coloration of the skin and mucous membranes, etc. Symmetrical pains of varying intensity in the joints, their slight swelling are typical for VA. Small joints of the hands (metacarpophalangeal and proximal interphalangeal), knee and ankle joints are more often involved.

With viral arthritis, morning stiffness may occur (rheumatoid-like variants). A favorite localization for arthritis after immunization against rubella is knee joints. Joint inflammation in rubella, hepatitis A, and alphavirus infection is predominantly acute and is accompanied by a marked increase in body temperature. Arthritis in hepatitis B, C, as well as during HIV infection is characterized by a chronic course and often manifests even before the detailed clinical picture of the underlying disease.

Only arthritis with HIV infection has the most specific and severe course. HIV-arthritis occurs in about 3% of cases within the framework of reactive arthritis (Reiter’s syndrome), manifested by urethritis, conjunctivitis and asymmetric arthritis of the lower extremities, deforming the joints. In a number of patients suffering from HIV infection, joint inflammation resembles psoriatic arthritis. At the same time, the patient’s fingers of the hands swell and acquire a bluish-purple color (“sausage-shaped fingers”), pain in the heels when walking and heaviness in the lower back bother.

Complications
The main complications are associated with pathology, against which arthritis develops (mainly with viral hepatitis B, C and HIV infection). Viral arthritis almost always regresses either independently or during the treatment of the underlying disease. Serious complications are extremely rare. With rubella, periarthritis and tenosynovitis of the tendons of the flexors of the fingers of the hand sometimes occur, which leads to carpal tunnel syndrome. The outcome of HIV arthritis can be osteomyelitis, avascular necrosis or acute bacterial arthritis, which quickly turns into a septic state.

Diagnostics
Patients with viral arthritis are supervised by rheumatologists, arthrologists and infectious diseases specialists. A decisive role in the diagnosis is played by a general examination of the patient (assessment of the skin, palpation of the liver) and anamnestic data (unprotected sex, blood transfusions). To confirm the inflammatory nature of joint pain, to determine the severity of joint damage, as well as to search for an infectious agent, an additional examination is prescribed, which includes:

Laboratory tests. The general blood test reveals signs of inflammation – accelerated erythrocyte sedimentation rate, leukocytosis, a shift of the leukocyte formula to the left. HIV infection, on the contrary, is characterized by leukopenia. In viral hepatitis, increased concentrations of hepatic transaminases (ALT, AST), total and direct bilirubin and gamma-glutamyltranspeptidase are noted in biochemical blood analysis.
Immunological studies. Antibodies to viruses, their DNA and RNA are detected in the blood by enzyme immunoassay and polymerase chain reaction. When infected with parvovirus and hepatitis C, high levels of rheumatoid and antinuclear factors, antibodies to double-stranded DNA are sometimes found in the blood.
Instrumental research. Joint radiography in most episodes of viral arthritis shows minor nonspecific inflammatory changes – a slight narrowing of the articular gap, periarticular osteoporosis, effusion into the synovial cavity. Severe damage is observed only in HIV-arthritis – pronounced erosion of the joints, their deformation, inflammation of the periarticular soft tissues.
Viral arthritis should be differentiated from rheumatic pathologies (ankylosing spondylitis, acute rheumatic fever, systemic lupus erythematosus). Pain and morning stiffness in the joints in combination with increased rheumatoid factor in the blood in VA caused by parvovirus B19 requires a thorough differential diagnosis with rheumatoid arthritis.

Treatment of viral arthritis
Patients are subject to hospitalization in a hospital, both because of the severity of their condition, and for the purpose of epidemiological isolation from others to prevent the spread of infection. Etiotropic therapy is the treatment of the underlying disease. This mainly concerns viral hepatitis C and B, HIV infection. Nonsteroidal anti-inflammatory drugs (NSAIDs) – diclofenac, ibuprofen – are used to relieve pain and relieve the inflammatory process in the joints. When NSAIDs are ineffective, glucocorticosteroids (prednisone), basic anti-inflammatory drugs (methotrexate, azathioprine) are used and synthetic antimalarial drugs (chloroquine).

Prognosis and prevention
In the vast majority of cases, viral arthritis is benign, easily amenable to therapy, and sometimes regresses independently without treatment. An unfavorable prognosis is associated with the underlying disease. HIV-arthritis in some patients can lead to persistent deformities of the joints, disabling patients. Prevention consists in preventing infection with viral infections (using condoms, avoiding the use of unboiled drinking water, unwashed fruits and vegetables). It is also necessary to observe general preventive measures to strengthen the immune system – a balanced diet, smoking cessation, regular exercise.

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