Varicella-associated arthritis occurring before the exanthem. Case report and literature review

Varicella arthritis in childhood: a case report and review of the literature

Nonbacterial arthritis is a rare but well-recognized complication of acute varicella in children. Reported cases usually described monoarthritis of the knee that occurs at the onset of the rash or shortly after. Herein, we describe a case of arthritis of the hip that occurred in a 4-year-old girl 6 days before the onset of rash. The presence of varicella-zoster virus DNA in synovial fluid was confirmed by real-time polymerase chain reaction. A review of the literature reported 26 previous cases of aseptic arthritis due to varicella infection among children.

Approach to knee effusions

The presence of an intra-articular knee effusion requires an extensive differential diagnosis and a systematic diagnostic approach. Pediatric knee effusions occur most commonly as acute hemarthroses after traumatic injury. However, the knee joint is susceptible to effusions secondary to a wide variety of atraumatic causes. Special attention is required in the atraumatic effusion to distinguish features of infectious, postinfectious, rheumatologic, hematologic, vasculitic, and malignant disease. This review discusses the various etiologies of both traumatic and atraumatic pediatric knee effusions highlighting the historical, physical examination, and laboratory characteristics to aid the emergency provider in diagnosis and initial management.

Association of measles virus with rheumatoid arthritis

OBJECTIVE

Rheumatoid arthritis (RA) is a chronic inflammatory polyarthritis; while the cause is unknown, it has been speculated that an infectious agent could be the trigger for the disease. Numerous attempts at isolating an agent have been unsuccessful. Our purpose was to identify a virus from diseased tissue from a patient with RA.

METHODS

Diseased tissue taken at the time of knee replacement surgery from a patient with RA was inoculated into several cell lines and observed for cytopathic effect. Cells from the tissue were also grown as explants and were examined for viruses. Synovial fluid drawn 4 years prior to the surgery and frozen at -70 degrees C was also inoculated into cell lines. Following the development of a cytopathic effect and identification of the agent, sera from 50 patients with rheumatoid factor (RF)-negative RA were examined for IgM antibodies to the agent.

RESULTS

After many inoculations and numerous subpassages, measles virus was identified in 6 cell lines inoculated with either the minced tissue or synovial fluid. Six cell lines co-cultivated with one or more of 9 explants also showed the presence of measles virus. Measles virus was confirmed by immunofluorescence and by neutralization. Eleven of 50 (22%) sera samples from patients with RF-negative RA had IgM antibodies to measles virus recombinant nucleoprotein.

CONCLUSION

There is an association between measles virus and RA.

Imaging of fungal, viral, and parasitic musculoskeletal and spinal diseases

There are many nonbacterial infections that have musculoskeletal manifestations and radiologic findings. These infections produce a limited range of tissue responses, depending on the organism, the tissue compartment affected, and the immune competence of the host. Diagnosis is dependent on obtaining an appropriate travel or geographic history, the clinical and laboratory features, and on occasion the specific radiologic findings.

Arthritis and vasculitis during the incubation period of varicella

Arthritis and vasculitis are very rare complications of varicella occurring almost exclusively after the eruption of the characteristic rash. We report two children, aged three and seven years, who developed vasculitis and polyarthritis (patient No. 1) and arthritis (patient No. 2) 13 and 9 days, respectively, before the onset of their typical varicella. Arthritis and vasculitis so early in the incubation period of varicella have not been described previously. In all previously reported cases the arthritis occurred after or together with the onset of varicella and only in one instance preceded the exanthem by 2 days. Although this may have been an unfortunate coincidence, an association between varicella zoster virus and these manifestations should be seriously considered. Clinicians confronted with such cases must be cautious and search for varicella infection, especially in times of epidemics.

Chicken pox infection (varicella zoster virus) and acute monoarthritis: evidence against a direct viral mechanism

A 9 year old boy developed acute monoarthritis of the left knee concurrent with the appearance of a varicella zoster virus (VZV) rash. Repeated VZV DNA hybridisation of the cells within the synovial fluid and synovial membrane failed to show any evidence of intracellular virus. Virus was isolated from synovial fluid 24 hours after the start of clinical infection but not later. These findings suggest that the mechanism of the arthritis is not due to viral replication inside the swollen joint.