A. General Presentation

1. Sudden onset of severe joint pain
2. Swelling may be present
3. Arthralgias and tenderness usually out of proportion to other findings
4. Skin rash present in most cases
5. History of "viral syndrome"

B. Etiology

1. Common
   1. Hepatitis B Virus
   2. Rubella virus / vaccine
   3. HIV
   4. Parvovirus B19
2. Uncommon
   1. Adenoviruses
   2. Coxackievirus
   3. Echovirus
   4. Gropu A arboviruses
   5. Hepatitis A virus
   6. Herpesviruses
   7. Mumps virus
   8. Vaccinia vaccine

C. Evaluation

1. Laboratory tests used to rule out other causes
2. CBC, Electrolytes, Renal functions, Liver Function Tests routinely
3. Consider ESR, ANA, RF, Hepatitis serologies
4. Specific Viral Tests
   1. Acute and convalescent titers usually required
   2. Cultures usually difficult
   3. Immunofluorescence studies
   4. HIV tests in any patients at risk
5. Other Tests
   1. Anti-streptolysin O (ASO) Titers to rule out streptococcal arthritis
   2. Blood Cultures, especially in IVDA, abnormal heart valves, etc.
   3. Lyme Titers
   4. Genitorurinary Cultures (rule out urethritis, PID, etc)

D. Parvovirus B19 [2]

1. ~60% of adults show evidence of past infection
2. Parvovirus causes childhood erythema infectiosum ("Fifth Disease")
   1. Pediatric rash usually asymptomatic
   2. Lacy erythematous rash most common in children
   3. Virus is endemic among schoolchildren
3. Parvovirus has been associated with chronic and acute arthritis / arthropathy [2,3]
   1. Parvovirus believed to be a major cause of acute and chronic arthritis
   2. Most cases are self limited, symmetric polyarthritis of large and small joints
   3. Some patients have chronic arthritis with up to 5 years of symptoms
   4. Parvovirus B19 DNA in synovial tissue is found in patients with and without arthropathy
   5. Serological responses to Parvovirus B19 (IgG) correlate with presence of Parvo DNA
4. Diagnosis
   1. Increased Anti-B19 IgM on ELISA in acute disease
   2. May last 2-3 month post infection
   3. High rate of baseline IgG in general population (correlates with presence of B19 DNA)

E. Hepatitis B Virus Associated Arthritis

1. Women more frequently than men
2. Probably due to early formation of immune complexes containing HBsAg
3. Associated Conditions
   1. Cryoglobulinemia (also especially with Hepatitis C Virus)
   2. Polyarteritis nodosa / Microscopic polyangiitis
4. Arthritis
   1. Usually sudden, severe
   2. Usually precedes frank jaundice
   3. Usually symmetric joint involvement; knees, hands, wrists
   4. May be migratory
   5. Usually last 1-3 weeks in acute attacks
   6. Chronic hepatitis B may include chronic joint symptoms
5. Urticaria may be associated with arthritis (probably related to bilirubin)
6. Laboratory Analysis
   1. All serologies (HBsAg, HBsAb, and HBcAb) must be obtained
   2. Complement levels usually low
   3. Cryoglobulins may be present
   4. Artherocentesis: 20-30K WBC with neutrophil predominance

F. Rubella Associated Arthritis

1. Usually affects young women with school aged children [4]
2. Typical morbiliform (punctate) rash
3. Typical "flu-like" syndrome
4. Eye pain, conjunctivitis, lymphadenopathy may occur
5. Vaccination with live attenuated vaccine may provoke attacks [4]
   1. Specific strains (RA27/3) are associated with increased induction of arthritis
   2. In general, vaccination in postpartum period increases risk of arthritis the greatest
   3. Rubella arthropathy is rarely chronic or damaging to joints
6. Neuropathy, often with lumbar plexus, may also occur

G. HIV Associated Arthritis

1. Subacute, oligoarticular arthritis
2. Severe intermittant pain, +/- synovitis may occur
3. Unclear if additional pathogen(s) is involved

References

1. Adebajo AO. 1998. Curr Opin Rheumatol. 10(1):79
2. Martin DP, Schlott DW, Flynn JA. 2007. NEJM. 357(18):1856 (Case Discussion)
3. Soderlund M, von Essen R, Haapasaari J, et al. 1997. Lancet. 349:1063
4. Tingle AJ, Mitchell LA, Grace M, et al. 1997. Lancet. 349:1277