Is multiple severe arthralgia (joint pain) a symptom of influenza (flu)?

Multiple Severe Arthralgia in Influenza

Multiple severe arthralgia (joint pain) is not a typical symptom of seasonal influenza but is more characteristic of chikungunya virus infection and other arboviral diseases. 1

Typical Influenza Symptoms

Influenza typically presents with:

• Fever (38-40°C), which is the paramount symptom, peaking within 24 hours and lasting 1-5 days 1
• Dry cough, though it may be productive in up to 40% of cases, especially in those with underlying lung disease 1
• Myalgia (muscle pain) affecting mainly the back and limbs 1
• Other symptoms include hot and moist skin, flushed face, injected eyes, and hyperemic mucous membranes 1

Arthralgia in Viral Infections

Influenza

• Influenza primarily causes myalgia (muscle pain) rather than arthralgia (joint pain) 1
• Joint pain is not listed among the common symptoms or complications of influenza in clinical guidelines 1

Arboviral Infections

• Multiple severe arthralgia is a hallmark symptom of arboviral infections, particularly chikungunya 1
• Chikungunya presents with systemic febrile illness and polyarthralgia/arthritis 1
• The American Heart Association notes that migratory polyarthritis (pain and swelling moving from one joint to another) is characteristic of certain conditions but not typical influenza 2

Chikungunya-Associated Arthralgia

• Chikungunya virus infection is characterized by high-grade fever followed by severe polyarthralgia 3
• Joint pain from chikungunya can persist for prolonged periods - approximately 40% suffer joint pain for up to 1 month and 7% beyond 1 year 3
• The most commonly affected joints are knee (96%), wrist (80%), and ankle (77%) 3
• Persistent arthralgia occurs in about 80% of chikungunya patients 3
• Risk factors for severe arthralgia in chikungunya include female sex and smoking 4

COVID-19 and Arthralgia

• Recent research has identified viral arthralgia as a manifestation of COVID-19 infection, though it occurs in only about 5.7% of patients with musculoskeletal symptoms 5
• COVID-19 arthralgia tends to be more severe and has variable onset compared to other musculoskeletal symptoms 5

Clinical Implications

• When evaluating a patient with multiple severe arthralgia during flu season, consider alternative diagnoses such as arboviral infections (particularly if in an endemic area) 1
• The presence of high-grade fever, involvement of four or more types of joints, and joint swelling are significantly associated with persistent arthralgia in chikungunya 3
• For patients with travel history to tropical regions presenting with severe arthralgia, dengue and chikungunya should be high on the differential diagnosis 1

Diagnostic Considerations

• Careful history taking should include recent travel to endemic areas for arboviral diseases 1
• Evaluate for other characteristic symptoms of specific viral infections (e.g., rash in chikungunya, respiratory symptoms in influenza) 1
• Consider serological testing for specific viral etiologies based on clinical presentation and epidemiological factors 1