To the Editor:

Evaluation of the diagnosis of recent-onset arthritis remains unclear. Specifically, no consensus exists regarding the relevance of viral serology (1). This is of importance, however, because arthritis can be observed during the course of numerous viral diseases, the viral tests used to diagnose recent-onset arthritis can vary widely among physicians (2), and rheumatoid arthritis (RA) should be accurately diagnosed early. We evaluated the relevance of routine hepatitis B virus (HBV), HCV, and parvovirus B19 serologic assessments in the diagnosis of arthritis or inflammatory polyarthralgia.

Consecutive patients seen at 2 rheumatology centers for inflammatory polyarthralgia, monarthritis, oligoarthritis, or polyarthritis of <1 year duration were included. Patients' serum samples were screened for the presence of anti-HCV antibodies (microparticle enzyme immunoassay and enzyme-linked immunosorbent assay). Positive samples were further evaluated for HCV-RNA with reverse transcriptase–polymerase chain reaction (RT-PCR). Sera obtained from patients who were hospitalized in the first center were screened for the presence of anti–parvovirus B19 antibodies, and sera from patients hospitalized in the second center were screened for the presence of HBV infection. A total of 322 patients (242 from the first center, 80 from the second) were included (218 women, 104 men; mean ± SD age 48.5 ± 16.2 years).

Patients were hospitalized for inflammatory polyarthralgia (n = 98), monarthritis (n = 36), oligoarthritis (n = 44), or polyarthritis (n =144). The mean ± SD disease duration was 5.7 ± 3.7 months.

Serum aminotransaminase levels were increased in 10.6% of the patients. HCV positivity was detected in 6 patients (2.7%), including 2 with previously diagnosed HCV infection. RT-PCR confirmed HCV infection in 2 of the 4 remaining patients, leading to 2 newly diagnosed cases of HCV infection (0.6%; 95% confidence interval [95% CI] 0.07–2.2). In one of these 2 patients, arthritis was not considered to be attributable to HCV infection. Two of the 242 patients in the first center were positive for parvovirus B19 IgM, but in one of these patients, the parvovirus B19 infection was not considered to be the cause of the joint symptoms. Therefore, only one patient (0.4%; 95% CI 0.01–2.3) was considered to have joint symptoms attributable to parvovirus B19 infection. Because this diagnosis was suspected at the time of clinical presentation, parvovirus B19 infection would have been diagnosed without performing routine serology. Additionally, a parvovirus B19 infection was suspected and diagnosed in a patient from the second center, who presented with fever, rash, and arthritis. HBV infection was never diagnosed in the 80 patients from the second center (0%; 95% CI 0–4.5). Other final diagnoses included RA (34.5%), other autoimmune diseases (15.5%), spondylarthropathy (12.3%), miscellaneous (14.6%), undifferentiated arthritis (17.4%), and undifferentiated arthralgia (4.4%). Table 1 shows the results obtained on subgroups with symmetric polyarthritis, polyarthralgia, disease duration ≤3 months, and increased serum transaminase levels. Additionally, the subgroup of patients with a disease duration <1 month was analyzed for the results of routine parvovirus B19 serology. Twenty-one patients from the first center met the criteria; among these patients, parvovirus B19 infection was diagnosed once.

Table 1. Percentage of patients with joint symptoms due to newly diagnosed HCV, HBV, and parvovirus B19 infections*
 Total patientsSymmetrical polyarthritisPolyarthralgiaDisease duration ≤3 monthsIncreased serum transaminase
  • *

    Values are percentage unless otherwise indicated. HCV = hepatitis C virus; HBV = hepatitis B virus; RF = rheumatoid factor; ANA = antinuclear antibodies; AKA = antikeratin antibodies; 95% CI = 95% confidence interval; PB19 = parvovirus B19.

Age, mean ± SD years48.5 ± 1649.7 ± 1650 ± 1648.6 ± 1745.7 ± 15
Disease duration, mean ± SD months5.7 ± 3.76.6 ± 45.2 ± 41.8 ± 13.4 ± 3
Positive RF3551.425.32734.8
Positive ANA3935.538.641.750
Positive AKA1935.610.611.714.3
Elevated serum transaminase10.
HCV diagnosis, % (95% CI)0.6 (0.07–2)0 (0–2.7)1 (0.2–5.6)0 (0–3.2)0 (0–11.6)
PB19 diagnosis, % (95% CI)0.4 (0.01–2.3)0 (0–3.1)0 (0–6)1.4 (0.03–7.8)0 (0–18.5)
HBV diagnosis, % (95% CI)0 (0–4.5)0 (0–19.5)0 (9.2)0 (0–8.4)0 (0–30.8)

In this study, results of routine HBV, HCV, and parvovirus B19 serologic assessments were found to be of weak relevance in the diagnosis process of recent-onset inflammatory joint disease. It must be pointed out that patients were recruited through tertiary referral centers, and that the results might have been different if recruitment had been performed through office-based rheumatologists or general practitioners. Thus, additional studies should be performed for confirmation.

The results obtained in the different subgroups were not different from those obtained in the whole population. In particular, although some practitioners restrict assessment of HCV and HBV serology to patients with joint disease and elevated levels of serum transaminase, the present results suggest that serum transaminase cannot be used as a test to determine which patients should be screened for HCV and HBV infection. These results must be interpreted bearing in mind that the usefulness of a routine diagnostic test also depends on the consequences of making the diagnosis. Because both HBV and, particularly, HCV infections can lead to cirrhosis and hepatocellular carcinoma, even a small percentage of positive cases on screening might be considered as being relevant. Moreover, another potential benefit of making the diagnosis might be the avoidance of administering inefficient, and potentially harmful treatments to patients wrongly believed to have RA. However, because the percentage of newly diagnosed cases with early-onset inflammatory arthritides was not different from that in the general population (3), screening cannot be considered to be more relevant in that particular group than in the general population.

  • 1
    Schaeverbeke T, Sibilia J, Fautrel B. Quels examens biologiques non immunologiques sont nécessaires pour éliminer une origine infectieuse ou microcristalline dans les rhumatismes inflammatoires débutants sans signe clinique d'orientation? Rev Rhum 2002; 69: 1629.
  • 2
    Saraux A, Maillefert JF, Fautrel B, Flipo RM, Kaye O, Lafforgue P, et al. Laboratory and imaging studies used by French rheumatologists to determine the cause of recent onset polyarthritis without extra-articular manifestations. Ann Rheum Dis 2002; 61: 6269.
  • 3
    Dubois F, Desenclos JC, Mariotte N, Goudeau A. Hepatitis C in a French population-based survey, 1994: seroprevalence, frequency of viremia, genotype distribution, and risk factors. Hepatology 1997; 25: 14906.

Amal Zerrak Jean Baptiste Bour MD*, Christian Tavernier MD*, Maxime Dougados MD†, Jean Francis Maillefert MD. PhD‡, * Dijon University Hospital Dijon, France, † Cochin Hospital, René Descartes University Paris, France, ‡ University of Burgundy and Dijon University Hospital Dijon, France.