What viral syndromes cause joint polyarthralgias primarily in the hands and ankles?

Viral Syndromes Causing Polyarthralgias in Hands and Ankles

Arthritogenic alphaviruses—particularly chikungunya virus—are the primary viral pathogens causing symmetrical polyarthralgias affecting hands (fingers, wrists) and ankles, with up to 80% of patients developing persistent musculoskeletal manifestations. 1

Primary Viral Culprits

Arthritogenic Alphaviruses (Most Common)

• Chikungunya virus causes symmetrical polyarthralgias or polyarthritis involving fingers, wrists, knees, ankles, and toes most frequently 1
• Ross River virus, Barmah Forest virus, Sindbis virus, o'nyong-nyong virus, and Mayaro virus all produce similar patterns of symmetrical peripheral polyarthralgia-polyarthritis 2
• These viruses are mosquito-transmitted and globally distributed, with chikungunya causing the largest recent epidemic (1.4-6.5 million cases from 2004-2011) 2

Hepatitis C Virus (HCV)

• HCV-related arthritis presents in two distinct patterns: symmetrical polyarthritis affecting wrists and hands, or intermittent mono-oligoarthritis typically involving ankles and other medium/large joints of lower limbs 3, 4
• Occurs in 4-5% of HCV-infected patients, though arthralgias are more common 3, 4
• The symmetrical polyarthritis subset shares features with rheumatoid arthritis but is non-deforming and non-erosive 3

Other Viral Syndromes (Less Specific)

• Rubella, cytomegalovirus, Epstein-Barr virus, mumps, Coxsackievirus, and adenovirus can cause polyarthralgias but typically resolve within 3 months 3
• These are less likely if symptoms persist beyond 3 months 3

Clinical Distinguishing Features

Alphavirus Arthritis

• Acute presentation: Fever, symmetrical polyarthralgias/polyarthritis, myalgias, and maculopapular rash 1, 2
• Chronic manifestations: Persistent or relapsing-remitting polyarthralgias lasting weeks to months, potentially years 1, 2
• Joint distribution: Fingers, wrists, knees, ankles, and toes are most frequently involved, though proximal joints and axial involvement can occur in chronic stages 1

HCV-Related Arthritis

• Symmetrical polyarthritis pattern: Involves wrists and hands symmetrically, positive rheumatoid factor in >50% of patients, but anti-CCP antibodies rarely detected 3, 4
• Intermittent mono-oligoarthritis pattern: Acute course with frequent relapses, closely related to cryoglobulinemic vasculitis manifestations 3
• Non-erosive and non-deforming: Less aggressive than rheumatoid arthritis, no rheumatoid nodules or bone erosions 3, 4

Diagnostic Approach

Key Laboratory Findings

• Inflammatory markers (ESR, CRP) are typically elevated in both alphavirus and HCV-related arthritis 4
• Anti-CCP antibodies are negative in viral arthritis, helping differentiate from rheumatoid arthritis 3, 4
• Rheumatoid factor may be positive in low titers in HCV-related arthritis but does not indicate rheumatoid arthritis 3, 4
• Serum cryoglobulins may be detected in HCV-related arthritis, though repeated testing may be necessary 4
• Viral serology: IgM and IgG antibodies for specific alphaviruses (chikungunya, Mayaro, etc.) 5, 2

Critical History Elements

• Travel history to endemic areas for alphaviruses (South America, Africa, Asia, Pacific regions) 1, 5, 2
• Timing: Alphavirus symptoms typically self-limiting but can persist; HCV arthritis is more chronic 1, 2
• Associated symptoms: Fever and rash suggest acute alphavirus infection; hepatic symptoms suggest HCV 1, 2

Treatment Considerations

Alphavirus Arthritis

• Acute phase: Acetaminophen and NSAIDs are recommended by the CDC 1
• Low-dose corticosteroids for 1-2 months may benefit acute symptoms 1
• Chronic manifestations: Hydroxychloroquine combined with corticosteroids or other DMARDs has been successful 1
• Methotrexate and sulfasalazine (alone or in combination) are effective for chronic alphavirus arthritis 1

HCV-Related Arthritis

• Low-dose glucocorticoids and hydroxychloroquine are usually effective 3, 4
• Antiviral therapy with interferon-free regimens should be considered, as viral eradication may resolve arthritis 3, 4
• Rituximab may be employed for refractory cases, particularly in the setting of cryoglobulinemic vasculitis 3, 4
• Avoid methotrexate and leflunomide due to hepatotoxicity concerns 3

Common Pitfalls

• Misdiagnosis as rheumatoid arthritis: Anti-CCP antibodies are the key differentiator—negative in viral arthritis, positive in RA 3, 4
• Overlooking travel history: Alphavirus infections are often imported cases in non-endemic regions 5, 2
• Assuming self-limitation: While most viral arthritis resolves, alphavirus arthritis can persist for months to years and may require DMARD therapy 1, 2
• Comprehensive viral testing has limited utility: Focus on epidemiological clues and specific serologies based on exposure history 6