Viral arthritis and arthralgias can be caused by or accompany several types of viral infections.1 Parvovirus, Hepatitis B and C, rubella, Epstein-Barr, alphaviruses, and Zika are among the most common viral agents associated with arthritis, while mumps, enteroviruses, and herpes viruses are some of the less common etiologies. While viral arthritis may be confused with reactive or infectious arthritis, these conditions are usually associated with bacterial infections rather than viral agents.2, 3
Viral arthritis epidemiology is in flux due to the global scale of the relevant viruses. The epidemiology is dependent on factors such as overall viral trends, the distribution of specific viral causes, outbreaks, and vaccination campaigns. The general trends in viral-induced arthritis are unclear. Globalization, increased travel, and better recognition may suggest an upward trend in prevalence. However, increased control of relevant viruses through vaccination, such as mumps and rubella, may indicate decreasing prevalence.
Precise data on the incidence and prevalence of viral arthritis is limited due to the wide variety of causal agents and considerable geographic fluctuations. However, studies suggest that approximately 1% of all acute arthritis cases have a viral cause.
More specific information on incidence, prevalence, and distribution depends on the underlying virus.1
Viral Arthritis Diagnosis & Presentation
The most common clinical presentation of virally mediated arthritis is symmetric polyarticular disease, with pain, swelling, or stiffness in joints on both sides of the body.1 Some may only experience joint stiffness (arthralgia), while others may report more classic symptoms of arthritis, such as pain and swelling.
With virally-induced arthritis, joint symptoms tend to arise suddenly, often during the acute phase of the infection. In some cases, a rash may develop at the same time. The arthritic symptoms of viral arthritis are usually transient and resolve without causing lasting damage to the joints.
While joint involvement may present similarly across cases of viral arthritis, the full scope of symptoms and disease patterns is largely dependent on the underlying virus. Some viruses have well-defined clinical features which, alongside serological testing, can aid in diagnosis.
However, not all viruses linked to viral arthritis have obvious clinical manifestations, and the signs of joint involvement may be difficult to connect with the overall viral symptoms. Below is a list of the potential etiologies to look for and their clinical manifestations4:
- Enterovirus (coxsackie, echovirus)
- Hepatitis viruses (mainly hepatitis B and C, rarely hepatitis A)
- Rubella (and rubella vaccine)
- Alphaviruses (ross river virus, chikungunya)
- Flaviviruses (dengue, zika)
- Herpesvirus (Epstein-Barr, varicella, cytomegalovirus)
- Human immunodeficiency virus (HIV)
The primary goal of a diagnostic workup for a potential case of viral arthritis is to determine whether the cause is viral and, if so, what virus is responsible. If a viral infection is not suspected, then the goal and the necessary steps will change to look for other potential causes of arthritic symptoms. The process should be guided by the findings at each stage and adjusted accordingly.
- Medical history and physical exam
- Perform a thorough medical history to assess the likelihood of viral involvement, focusing on symptoms, timeline of symptoms, possible exposure to viral agents, and recent vaccinations
- Gather a history of recent travel to determine potential exposure to relevant viruses
- Physical exam
- Examine joints for swelling, warmth, tenderness, pain, and range of motion1
Based on a patient’s medical history and physical manifestations, virally-mediated arthritis may be suspected because of the following features:
- Joint inflammation or pain in multiple joints with an acute onset (lasting less than six weeks)
- Well-defined clinical signs such as a distinct rash indicative of rubella, or inflammation of the parotid gland that is suggestive of mumps
- Suggestive historical findings, such as recent travel, potential exposures, or recent rubella vaccination1
If viral involvement is suspected, the diagnostic protocol may include the following viral arthritis blood tests:
- Serologic testing of IgM and IgG antibodies for several suspected viral agents1
- Serum should be collected as soon as possible and tested for the relevant viruses (those suggested by earlier findings).
- The first round of serum tests will target IgM antibodies to look for an initial IgM response against the suspected virus.
- Serum should be taken again after roughly 2 to 3 weeks.
- A retest for IgM antibodies, if none were detected during the first round of serum tests, for those at high risk for viral arthritis. The second round of serum tests target IgG antibodies to look for the delayed IgG response against the suspected virus.
- A viral cause is confirmed by serological testing if both steps are identified — the acute IgM response and the subsequent development of IgG antibodies.
- A recent viral infection may be suspected if the initial test fails to capture the initial IgM response due to delayed sample collection, but a significant and timely IgG response is identified.
If viral involvement is unknown, the diagnostic protocol may include the following:
- Complete blood count
- Erythrocyte sedimentation rate
- C-reactive protein
- Liver function tests
- Muscle enzymes
- Rheumatoid factor tests
- Anti-citrullinated peptide antibodies tests
- Antinuclear antibodies tests
- Synovial fluid analysis
- White blood cell count and differential
- Crystal search
- Gram stain
- Routine culture
If there is no indication of a specific viral cause, and tests for nonviral etiologies were negative or inconclusive:
- Serological testing for standard viral agents4:
- Hepatitis B
- Hepatitis C
If serum tests do not indicate specific viral etiologies, the following diagnoses may be considered and tested for:
- Other rheumatological disease including
- Rheumatoid arthritis
- Systemic lupus erythematosus
- Juvenile idiopathic arthritis
- Oligoarticular-onset Juvenile idiopathic arthritis
- Bacterial infections including:
- Crystal disease
- Mycoplasma infection
Viral Arthritis Management
Viral arthritis management strategies are highly variable depending on the viral agent. Only a small subset of the viruses linked to arthritis have specific antiviral therapies that are currently available, including hepatitis B, hepatitis C, and HIV. Since virally mediated arthritis and arthralgias are usually self-limited, management and treatment should be guided by the severity of symptoms and the necessity of treatment, balanced with any potential risks or side effects.
The management of viral arthritis is dependent on the underlying viral infection and the severity of symptoms. However, most cases are treated with therapies aimed at symptom relief, including analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs) (at similar dosages to other arthritic conditions), and in more severe cases, physical and occupational therapy. Glucocorticoids provide limited benefits for viral arthritis and are generally not recommended.
Most cases of viral arthritis resolve on their own within days or weeks, depending on the duration of the underlying infection. These cases of transient viral arthritis typically do not require specific antiviral treatments. In some cases, additional therapies or antivirals may be useful in managing the underlying viral infection.5
Monitoring Viral Arthritis Side Effects
Side effects, adverse events, and drug interactions are generally minimal or predictable if management is focused on symptom or pain relief. If management is aimed at the underlying viral infection, the treatment options and associated risk profiles are highly variable.5
It is typically unnecessary to monitor for signs of chronic disease or recurrence because most cases are acute and will not recur. However, there are rare exceptions, especially in cases caused by rubella, parvovirus, EBV, chikungunya, and other types of alphaviruses. Still, these cases tend not to cause chronic or long-term joint disease.6
1. Moore TL. Viral arthritis: Approach to evaluation and management. UpToDate. Updated May 3, 2022. Accessed June 28, 2022.
2. Reactive arthritis. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Reviewed September 2021. Accessed June 28, 2022.
3. Infectious arthritis. Arthritis Foundation. Accessed June 28, 2022.
4. Marks M, Marks JL. Viral arthritis. Clin Med. 2016;16(2):129-134. doi:10.7861/clinmedicine.16-2-129
5. Moore TL. Viruses that cause arthritis. UpToDate. Updated November 25, 2020. Accessed June 28, 2022.
6. Villa-Forte A. Evaluation of the patient with joint symptoms. Merck Manual. Updated February 2022. Accessed June 28, 2022.
Serena McNiff is a journalist covering health and science. Her work has appeared on HealthDay, CNBC, WebMD, U.S. News, and more.