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HCV-ASSOCIATED ARTHRITIS

Spondyloarthritis (or spondyloarthropathy) is the overall name for a family of inflammatory rheumatic diseases that can affect the spine and joints, ligaments and tendons. These diseases can cause fatigue and pain or stiffness in the back, neck, hands, knees, and ankles as well as inflammation of the eyes, skin, lungs, and heart valves. While there is no course of prevention at this time, treatment can reduce discomfort and delay the development of spinal deformities.

Fast Facts

HCV-associated rheumatic disorders are very common in HCV positive patients. Often the infection is latent, commonly following a contaminated blood transfusion.

Patients recently diagnosed with arthritis or cryoglobulinemia (an abnormal protein in the blood) should be tested for HCV infection.

Some medicines used to treat HCV, such as interferon, can induce or increase HCV-associated rheumatic disorders.

What are HCV-associated rheumatic diseases

HCV-associated rheumatic diseases are disorders of the joints and muscles that can result from the HCV virus. Painful joints and muscles combined with fatigue are usually the first and most common complaints.

Less common, but as important, rheumatic disorders that can occur include joint swelling (as differentiated from rheumatoid arthritis), multiple painful joint locations as in fibromyalgia, and inflammation of blood vessels (vasculitis).

Some medicines used to treat HCV, such as interferon, can induce or increase HCV-associated rheumatic disorders.

What are HCV-associated rheumatic diseases

What causes HCV-associated rheumatic diseases

The musculoskeletal complications of HCV-associated rheumatic disorders are a reaction to the immune system's fight against the virus. This leads to the formation of immune complexes (formed by the HCV or "antigen" combining with the patient's antibody against HCV) as well as the production of abnormal proteins called cryoglobulins.

Cryoglobulinemia (certain abnormal proteins in the blood) may cause blood vessel problems, particularly during cold weather. This often results in a Raynaud’s phenomenon which causes fingers to whiten in the cold. Given HCV infection is the most common cause of cryoglobulinemia, patients with recent Raynaud’s phenomenon should be tested for HCV infection.

The white material in the bottom of the test tube is due to the presence of a cryoglobulin, an abnormal protein in the blood.

How they are treated

Typically HCV treatment combines interferon with antiviral medicines such as ribavirin. While the use of this antiviral therapy has improved control of liver damage caused by the virus, it unfortunately can cause the development or increase the intensity of HCV-related symptoms including inflammatory musculoskeletal complaints.

Control of resulting joint problems is limited by the use of drugs which can have their own liver toxicity or increase virus activity. Fortunately, based on studies that looked back at how joint symptoms were treated in HCV patients, the use of methotrexate, the most common treatment for rheumatoid arthritis, appears to be relatively safe and effective in HCV patients. Rheumatologists and liver doctors can work together to treat these patients.

More recently, anti-TNF agents have further improved the efficacy of the treatment of rheumatoid arthritis. Their use in HCV patients appears to be safe, with no liver toxicity or increase in viral replication. Effectiveness in this patient population, however, seems lower than that observed in rheumatoid arthritis.

Who gets HCV-associated rheumatic diseases

HCV-associated rheumatic disorders affect individuals of all ages, ethnicities and genders who have the HCV virus.

The major mode of infection is through blood transfusions already contaminated by the virus itself. IV drug abuse is another mode of contamination. Unlike HIV, unprotected sex with infected individuals is a less common cause. However, patients positive for HCV should be tested for HIV and those with HIV should be tested for HCV.

How HCV-associated diseases are diagnosed

Because clinical symptoms of HCV are frequently absent, blood tests to diagnose HCV infection have to be used more widely, particularly in patients with hepatitis, arthritis and fatigue. These tests are easy to perform and are reliable.

The diagnosis is based on the detection of antibodies against the virus in the serum and confirmed by the detection of the virus in the blood. This allows physicians to determine the virus replication (that is, how fast the virus is making copies), which is its level of activity. This assessment is used for follow-up.

The white fingertips are an example of Raynaud's phenomenon.

How they are treated

Prevention

Better screening of blood transfusions has largely reduced the occurrence of blood-related HCV contamination.

On an individual basis, reducing risk factors associated with HCV, as with HIV, can help prevent the spread of the virus.

Living with HCV-associated diseases

HCV-associated musculoskeletal manifestations cause discomfort in everyday life. Because treatment is complex, communication between the physicians in charge of treating HCV-related liver disease and the physicians in charge of treating the symptoms related to HCV besides the liver is needed. This quality interaction also contributes to the necessary long term follow-up of any HCV positive patient, since the liver disease can become progressively worse, leading to liver failure or liver cancer.

Patient support groups also provide helpful support and coping suggestions.

Red areas show location of inflammation in the sacroiliac joints.

Points to Remember

Any musculoskeletal syndrome can be the consequence of an HCV infection, even in the absence of hepatitis.

HCV-associated rheumatic disease may occur before the diagnosis of HCV infection.

Treatments of these manifestations do exist but are better used in a context of a multi-disciplinary interaction between physicians taking care of the patient.

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