Reports of rheumatic symptoms persisting three years after people are diagnosed with acute arbovirus infections are common – but may also be a case of mistaken identity.
A Columbian study of 500 patients with clinically and serologically confirmed chikungunya virus (CHIKV) infection found 123 reported persistent joint pain a median of 20 months after their infection and 65 patients reported persistent symptoms out to 40 months.
More than half of patients reported their joint pain involved periods of relief then relapse with exercise, infection, immobility and household activities reported as some of the pain triggers.
A significant minority of patients with chronic joint pain (39%) also reported morning stiffness and 30% reported stiffness at other times of the day.
A similar number of patients (38%) reported missing school or work due to their persistent symptoms.
The study, published in the Journal of Rheumatology, said there were many resemblances between CHIKV-associated arthritis and rheumatoid arthritis including the cytokine secretion.
“Periarticular and systemic bone loss are also common in both RA and CHIKV-associated arthritis, resulting from an inflamed synovial membrane; however, the focal bone erosion and articular cartilage thinning found in patients with RA is not seen in post-CHIKV arthritis,” the study said.
It noted that the persistent joint pain and other symptoms could also be due to another aetiology and misattributed to the CHIKV infection.
Commenting on the study, Professor Andreas Suhrbier told the limbic he was skeptical that the symptoms were related to the original infection without rigorously ruling out differential diagnoses.
“We need to extend to patients the same diagnostic rigour that you would extend to someone with no previous diagnosis of CHIKV,” he said.
He said patients can have persistent IgM levels but that didn’t mean they had persistent disease.
Professor Suhrbier, group leader in inflammation biology at QIMR Berghofer Medical Research Institute, said the same issue had previously arisen with Ross River infections in Australia.
As reported earlier this year in the limbic, he said Ross River disease rarely lasted longer than 3-6 months. Any arthropathy beyond that was usually another disease.
He said it was possible that chronicity was more of an issue with CHIKV given it was a more serious disease than Ross River, capable of leading to serious manifestations including viral shock, hospitalisation, organ failures and death.
However in a recent Nature Reviews article on rheumatic manifestations of CHIKV, Professor Suhrbier said difficulties remain in separating chronic CHIKV arthropathy from the progression of underlying comorbidities or the development of new disease entities.
“The prevalence of musculoskeletal disease is increasing, with disability-adjusted life-years for musculoskeletal conditions having risen by 61.6% between 1990 and 2016, and by 19.6% between 2006 and 2016,” he wrote.
“Musculoskeletal conditions include >150 diagnoses, with about a third of people worldwide living with a chronic, painful musculoskeletal condition. Therefore, a patient presenting with a musculoskeletal condition might be granted the same diagnostic rigour, regardless of whether or not they had a diagnosis of chikungunya >6–12 months previously.”