In the background of recent increase in viral arthritis cases, we are discussing the topic and it relevance to the time present

Infectious arthritis

Joints pain and swelling caused by microbiological entities are called as infectious arthritis. These can be caused by  bacteria, fungus or virus. Bacterial infections can be acute or chronic. Most acute infections are caused by Staphylococcus, streptococcal, E. Coli, Peudomonas aeruginosa and others. These conditions are medical emergencies and to be treated properly or may lead to damaged to the joints. Chronic bacterial infections of the joints are usually caused by Tuberculosis or Leprosy. Fungal infections of the joints are very rare. Usually seen in immune-suppressed patients.

Viral arthritis

Arthritis can be also caused variety of viruses. To name some of them – Parvovirus B, Rubella, ( Rubella vaccination also can cause arthritis), HIV, hepatitis B and C. the most common viral arthritis that may present in epidemics are caused by Alpha viruses which are mosquito born. Common are the Chikungunya and dengue infections. The other rare causes of joints pain include herpes virus, Epstein barr virus, mumps, adenovirus and coxsackie virus. Joints pain are sometime part of other viral syndromes which are more frequently described with sore throat or upper respiratory infections

Chikungunya arthritis

Chikungunya – the name is derived from it’s the place where it was first isolated around 50 years back. In Makondelanguage ( in Mozambique) it means “that twists or which bends”. The literal meaning itself implies the severity of the infection with the person in stooped posture. When Chikungunya affects a person, the person would be having severe pain and arthritis that makes him bend to walk around. Initially these were described in the African countries but later also identified in Asia continent. Epidemics of Chikungunya have been described. Large epidemics in India were described in 1962 and also in 2006-2007. Synovitis is thought to due to direct viral infection to the synovium.

It affects all age group persons and has no gender predilection. It is usually self limiting and not life threatening. The clinical features are almost similar to dengue infections but the most extreme dengue hemorrhagic condition is not seen with Chikungunya. Typical symptoms include high grade fever at the onset with severe joints pain. Fever may last for 1-7 days. On the second day of fever rashes may also appear. Rashes last for 2-5 days. Arthralgia is described in almost 100% of cases. These may be associated with other general symptoms like myalgia, pharyngitis, loss of appetite, nausea, vomiting, headache, few petichiel spots,skin peeling,  red eye, eye pain and back pain. Most episodes resolves with weeks but about 5-10 percent of patient may have persistent joints pain for months and very rarely for years as recurrent or persitant joints pain.. Diagnosis can be made by virus isolation (which is rarely done in our setting). Detection of IgM antibody may suggest Chikungunya infection. But the antibody may be present as long as six months.

No anti Chikungunya virus drug is available. The management is symptomatic. For arthralgia, use paracetamaol or NSAIDs (Non Steroidal Anti Inflammatory Drugs) at appropriate doses. If the patient responds to this then has to be maintained for certain period of time before it is stopped. The duration of treatemtn with NSAIDs are not defined. Some patients who do not respond to this may need steroid for short duration. The role of Hydroxychloroquinine is controversial. But can be used if both these treatment fails. Vaccination for chikunguya infection is still under experimental stage and not commercially available.

Chikngunya is newly emerging old infection and it is been taking new social, political and public health importance. Chronic and recurrent arthralgia were socially disabling in the olden days, but now has a serious economic importance.

Recent experience –

In the last two weeks there has been a surge of cases with viral arthritis. We have also noticed that there is raise in cases with dengue also. Typically patients present with fever episode with mild arthritis and 2-4 weeks later develop increasing pain and stiffness in the joints. Joints most commonly involved are the small joints of the hands and foot but rarely large joints like knees, hips, elbows and shoulders. There are few cases with swelling of the foot and skin peeling of the hands and foot. Majority of them have responded to NSAID treatment. Around 10-20% required steroid therapy. The duration of treatment is individual. It depends on the time for complete response of all the symptoms. There were few cases with proven chikungunya and dengue serology. But majority have not been evaluated for the infectious agent. This is because of the time lapse from the initial symptom onset and the onset of arthritis.

Just to reiterate the importance of prevention of the disease is more important than treating the disease. The pain undergone is only known to the person who has it. So, it is the responsibility of every individual to prevent the vector borne disease.