Viral Arthritis / Arthralgia
Introduction
- Viral
infection หลายชนิดสามารถทำให้เกิด arthralgia หรือ arthritis ได้
- กลไก: direct invasion ของ joint
tissue, immune complex deposition, cytokine dysregulation
- ส่วนใหญ่เป็น acute, self-limited arthritis ไม่ทำให้เกิด erosive joint damage
- Chronic
arthritis จาก viral infection พบได้ไม่บ่อย
(ยกเว้น chikungunya, Ross River, บางกรณีของ parvovirus,
rubella)
Etiology
กลุ่มไวรัสสำคัญที่ทำให้เกิด arthritis/arthralgia:
- Parvovirus
B19 →
polyarthritis คล้าย RA, additive, small joints,
morning stiffness, transient autoantibodies
- Alphaviruses
→ chikungunya, Ross
River, Barmah Forest, Sindbis, Mayaro, O’nyong-nyong → มักทำให้ arthritis
เกือบทุก case, อาจ persistent
>6 เดือน (โดยเฉพาะ chikungunya)
- Flaviviruses
→ Zika (arthralgia
small joints), Dengue (“break-bone fever”, arthralgia 60–80%)
- Hepatitis
viruses →
- HAV:
rare, arthralgia + rash (prodrome)
- HBV:
acute infection 10–25%, RA-like, migratory, self-limited, resolve หลัง jaundice
- HCV:
arthralgia, cryoglobulinemic vasculitis, frank arthritis rare
- Rubella
virus/vaccine →
abrupt-onset arthritis, small joints, females > males, self-limited;
vaccine: arthralgia/arthritis 0.5–25%
- HIV
→ acute HIV
arthralgia, HIV-associated arthritis, painful articular syndrome, reactive
arthritis (HLA-B27 related), PsA, IRIS-related inflammatory disease
- Herpesviruses
→ EBV (arthralgia,
rare arthritis), VZV (monoarthritis knee), HSV (rare, self-limited), CMV
(rare, immunocompromised, polyarthritis)
- Others
→ Mumps (rare,
migratory polyarthritis), Adenovirus (rare, self-limited), Enterovirus
(very rare, 0.1%)
- Coronavirus
(SARS-CoV-2) →
rare post-reactive arthritis, MIS-C arthralgia
Common Clinical Features
- Sudden-onset
polyarthritis (acute < 4 wk)
- Nonerosive,
self-limited
- Associated
viral prodrome: fever, rash, lymphadenopathy, hepatitis, conjunctivitis,
parotitis
- Geographic/travel
history สำคัญ (เช่น endemic arboviruses)
- Vaccination
status → rubella
vaccine-related arthralgia
Evaluation & Diagnosis
- History
& PE → joint
exam for synovitis, pattern of joint involvement (symmetric small joints
in parvovirus, migratory in HBV/rubella, additive in chikungunya)
- Red
flags viral cause →
acute polyarthritis + viral prodrome (rash, fever, exanthem, travel to
endemic area)
- Labs:
nonspecific, may mimic autoimmune (ANA, RF, anti-dsDNA positive
transiently in parvovirus, HBV, HCV)
- Viral-specific
testing only if clinical suspicion หรือ public
health implication (HIV, HBV, HCV, rubella, arboviruses)
- Synovial
fluid: nonspecific inflammatory, viral isolation uncommon
- Diagnosis
→ clinical &
presumptive; confirm when systemic viral infection identified and
arthritis resolves
Differential Diagnosis
- Early RA,
SLE, JIA, PsA, spondyloarthritis
- Crystal
arthropathy (gout, CPPD)
- Septic
arthritis (esp. acute monoarthritis)
- Post-infectious
reactive arthritis
Management
- Supportive
- NSAIDs,
acetaminophen
- Avoid
aspirin in children (Reye syndrome)
- Physical/occupational
therapy if functional limitation
- Glucocorticoids
→ generally avoid; may
use short tapering course (prednisone <
15 mg/day, < 1 wk) in debilitating cases
- Antiviral
therapy → ตาม indication ของ infection (เช่น HBV, HCV, HIV) แต่ arthritis มัก resolve เอง
- Chronic/persistent
arthritis (เช่น chikungunya) → อาจใช้ DMARDs/biologics
แบบ RA (แต่ evidence จำกัด)
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✅ Clinical Pearls
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