Certain common viral illnesses may present in patients with inflammatory rheumatic disease

CHICAGO — During the American College of Rheumatology State-of-the-Art Clinical Symposium, Beth L. Jonas, MD, discussed the common viral illnesses that may present alongside inflammatory rheumatic diseases.

Hepatitis A is fairly common, Jonas said; however, the symptoms are mild, and patients usually present with gastric symptoms and occasionally mild arthralgia.

According to Jonas, these patients rarely make it to a rheumatologist because the disease is self-limiting and symptoms tend to resolve in a short period of time.

With regard to hepatitis B, arthralgia and arthritis have presented as acute infections; however, infection has become less common because childhood vaccinations are common, and cases usually arise in patients who have traveled from Asia, according to Jonas.

“Most patients are asymptomatic for a long time before the disease becomes chronic,” she said. “Chronic arthralgia and arthritis is very unusual in this population, but those patients may present with vasculitic syndrome.”

Jonas said the patients most commonly seen by rheumatologists are those with hepatitis C (HCV). Most patients are not diagnosed until the disease becomes chronic, she said. The disease is both hepatotrophic and lymphotrophic and is associated with numerous rheumatic diseases, such as cryoglobulinonemic vasculitis, arthritis and polyarteritis nodosa. Although, interferon therapy can induce autoimmune responses that may present with symptoms associated with lupus, newer antiviral drugs prescribed to patients with HCV by hepatologists may reduce these presentations in the future, according to Jonas.

Mixed symptoms are often present in patients with HCV, and patients who develop chronic arthritis are more likely to be women, older in age and have more advanced hepatic fibrosis, she said. Almost half of patients with HCV will demonstrate mixed type 2 or 3 cryoglobulins, and they are usually positive for rheumatoid factor (RF). A small percentage develop vasculitis, Jonas said, and synovitis may or may not be present. Erosive arthritis is unusual in patients with HCV, according to Jonas.

Parvovirus B19 is another common viral illness with which many people are infected, develop IgG antibodies but then do not present with more than mild flu-like symptoms, Jonas said. About 2 weeks after infection, the onset of inflammatory arthritis may occur. Symptoms usually involve symmetrical, small joints of the hands, wrists and knees and a rash. Jonas said symptoms usually resolve in 1 month to 2 months, but some patients have persistent disease.

Only 10% of children and 50% of adults have rheumatic symptoms, and infection is most likely in the spring, she said.

Chikungunya was first described in Africa and the geographic distribution is now widespread, including in the southern U.S. and often presents with arthralgia.

Almost all patients with chikungunya develop fever, chills and polyarthralgia, especially in patients older than 54 years of age. Arthritis in patients with chikungunya can last more than 6 weeks and after 2 years, 5% of patients in one study still had arthritis. The most common joints affected were in the wrist, hand, knee and ankle, according to Jonas.

“Consider infections in the differential diagnosis of patients with arthritis,” Jonas said. “It is most commonly viral diseases. [Also], be aware that chikungunya may be coming to a hospital near you. Ask patients about travel.” - by Shirley Pulawski

Reference:

Jonas B. Session II, lecture #3. Presented at: American College of Rheumatology State-of-the-Art Clinical Symposium. May 2-3, 2015; Chicago.

Disclosure: Jonas reports no relevant financial disclosures.