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Monkeypox can also induce arthritis! The Lancet publishes the first case on World Arthritis Day

 Last Update: 2023-01-07
 Source: Internet
 Author: User

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World Arthritis Day
is celebrated annually on 12 October.
It is reported that there are 355 million people with arthritis in the world, which has become one of
the most disabling diseases.
In Asia, one in six people has
arthritis.
Therefore, the prevention and treatment of osteoarthritis is an issue
that the whole society needs to pay attention to.
Monkeypox is a zoonotic viral disease caused by monkeypox virus (MPXV) infection, which is mainly manifested clinically as fever, rash, and lymphadenopathy
.
However, Lancet Rheumatol.
3 recently published the first monkeypox-induced arthritis case to ^date3
, suggesting that monkeypox may affect joints.

Monkeypox is predominantly endemic in Central and West Africa, with cases of monkeypox and community transmission in some non-endemic countries since May 20221^.
In June, the Chinese Journal of Infection Control published the Guidelines for the Diagnosis and Treatment of Monkeypox (2022 Edition) to improve clinicians' ability
to identify monkeypox early and standardize diagnosis and treatment.
By mid-July 2022, more than 60 countries around the world had reported more than 10,000 confirmed cases of monkeypox and deaths, causing widespread concern among scholars at home and ^abroad2
.

Case details

A 31-year-old HIV-positive male was admitted to hospital on 30 June 2022 with symptoms of hand vesicular eruption (figure A), perianal lesions, inguinal lymphadenopathy and right knee arthralgia
.
With antiretroviral therapy, the HIV viral load was below the lower limit of detection and the CD4+ T cell count was 802/microliter
.
Considering the increase in monkeypox infections in Europe at that time, it is suspected that it was infected with monkeypox virus
.
PCR results from two different skin lesion specimens showed monkeypox virus positive (cycle thresholds of 20 and 21).

The patient was then discharged and self-isolated
.

Fig.
1 Herpes of the left hand (A), swelling of the right knee (B), synovitis on MRI (red circle; C), obvious edema of the medial femoral condyle (red circle; D), joint effusion, marked edema (green arrow), and subchondral dividing line (red circle; E）

Initial appearance of joint effusion

Follow-up after 11 days showed complete resolution of the rash and lymphadenopathy, but significant swelling of the right knee (figure B).

Arthrocentesis, inhalation of 60 ml of cloudy synovial fluid
.
Analysis of synovial fluid showed a total number of cells of 16127/μL, of which 88.
5% were lymphocytes and 11.
5% were neutrophils
.
Synovial fluid PCR is positive for monkeypox virus (cycle threshold of 27).

C-reactive protein was slightly elevated to 18mg/L, and there was no significant difference
in other laboratory test results.
Synovial fluid was negative for bacterial culture and wide-range PCR, rheumatoid factor serology, anti-citrullinated protein antibodies and antinuclear antibodies, human leukocyte antigen B27, and Lyme disease PCR
.

Reproduction of joint effusion

Eight days later, the joint accumulates fluid again and a second joint puncture
is performed.
Synovial fluid PCR again showed monkeypox virus positive (cycle threshold of 33), while whole blood PCR showed monkeypox virus negative
.
MRI showed synovitis, joint effusion, and significant edema at 1 cm of the subchondral demarcation line in the medial femoral condyle, consistent with the diagnosis of arthritis and osteomyelitis (Figures C-E).

Patients were given NSAIDs, and symptoms of arthralgia and swelling improved
within 3 weeks.

Case discussion

Viral infections are a common cause of arthritis, but viral bone infections are rarely reported
.
Monkeypox virus, smallpox virus, vaccinia virus and vaccinia virus belong to the four viruses that cause disease to humans in the genus Orthopoxvirus of the pox viridae family, and they have basically the same antigen properties and cross-immunity to each ^other2
.
Viral osteomyelitis is a classic complication of smallpox and is called smallpox osteomyelitis
.
To date, there are no documented cases
of monkeypox-associated arthritis or osteomyelitis.
Given the association between smallpox virus and monkeypox virus, monkeypox virus may be thought to cause arthritis and underlying osteomyelitis
.

Monkeypox is a zoonotic disease that has been shown to spread widely from person to person, and this outbreak has spread
rapidly in non-endemic countries and regions.
However, scholars generally agree that an outbreak of monkeypox in China is ^unlikely2
.
According to the Guidelines for the Diagnosis and Treatment of Monkeypox (2022 Edition)¹, most monkeypox patients have swollen lymph nodes in the neck, armpits, groin and other parts
.
The rash
appears 1~3 days after the onset.
Some patients may present with complications, including secondary bacterial infection of the lesion site, bronchopneumonia, encephalitis, corneal infection, and sepsis
.
There is no mention of the possibility of arthritis in the patient, which may fill this gap
.

In terms of treatment, only nonsteroidal anti-inflammatory drugs were used for symptomatic treatment
in this case.
According to the Guidelines for the Diagnosis and Treatment of Monkeypox (2022 Edition), there are currently no specific anti-monkeypox virus drugs in China, mainly symptomatic support and treatment of complications
.
For those with high body temperature, physical cooling is the mainstay, exceeding 38.
5 °C, antipyretic analgesics to reduce fever; analgesics can be given when the pain is severe; preventive use of antibacterial drugs is not recommended
.
In addition, the guidelines also mention giving patients psychological support treatment to relieve psychological problems such as tension and anxiety, and appropriate use of traditional Chinese medicine
.
Moreover, monkeypox is a self-limiting disease, and most infected people have a good
prognosis.

References:

1.
Guidelines for the diagnosis and treatment of monkeypox (2022 edition)[J].
Chinese Journal of Infection Control,2022,21(6):600-601.
DOI:10.
12138/j.
issn.
1671-9638.
20222293.

2.
MA Xiang, ZHENG Yuejie, YANG Yonghong, et al.
From smallpox to monkeypox, how to deal with the monkeypox challenge? [J].
Chinese Journal of Practical Pediatrics,2022,37(13):961-963.
DOI:10.
3760/cma.
j.
cn101070-20220628-00786.

3.
Mirella Fonti, Theresa Mader, Jan Burmester-Kiang,et al.
Monkeypox associated acute arthritis[J].
Lancet Rheumatol .
2022 Published Online September 12, 2022 https://doi.
org/10.
1016/ S2665-9913(22)00257-0

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