Echovirus‐associated polyarthritis. report of a case with synovial fluid and synovial histologic characterization

Abstract

A patient with fever, myalgias, and acute polyarthritis in whom echovirus 9 was isolated from throat and rectal swab specimens is described. All symptoms resolved spontaneously over a one week period except for the arthritis which required three months for complete recovery. A mildly inflammatory synovial fluid and histologic picture were observed. Attempts to isolate the virus from synovial fluid and synovium during acute illness were unsuccessful.Although echoviruses are recognized producers of a wide spectrum of human illness, arthritis is generally not considered part of this spectrum (1-3), or at most is an exceedingly rare occurrence in echovirus infections (43). Only one weakly documented case of acute arthritis attributed to echovirus is reported in the English language literature (4). A second case documented by viral isolation is reported here and presents the hitherto undescribed synovial fluid and synovial histologic findings. CASE REPORTA 35-year-old female bookkeeper was admitted to the Hospital of the University of Pennsylvania on July 18, 1970 with complaints of fever and myalgias. On July 15, the patient awoke with a painful right shoulder. By evening, chills, fever, and myalgias had developed coincident with marked neck stiffness and pain in both shoulders and the right arm. The shoulders, elbows, ankles, and right metatarsophalangeal (MTP) joints became painful with conspicuous swelling of the knees, ankles, and right MTP joints. The patient was prescribed phenylbutazone by her local physician but noted no symptomatic relief. She denied cough, coryza, sore throat, conjunctivitis, alopecia, mouth ulcers, jaundice, pruritis, Raynaud's phenomenon, nausea, vomiting, abdominal discomfort, or vaginal discharge. The day prior to admission, she noted three small evanescent erythematous skin lesions on her arms. There was no past or family history of rheumatic fever or joint disease. The patient denied recent immunizations or exposure to jaundiced or otherwise ill persons.On admission, she was alert but in obvious distress from painful joints and was unable to walk. Her oral temperature was 39°C (102°F). N o skin eruptions or adenopathy were noted. There was conspicious nuchal rigidity with painful limitation of neck motion. The mandible was tender with painful temporomandibular joint limitation of motion. Diminished right shoulder range of motion without effusion was present. Erythema and tenderness over the left ulnar styloid without wrist effusion were noted. Bilateral non-erythematous relatively non-tender knee effusions were evident, The medial aspect of the left ankle was erythematous, swollen, and tender. The right ankle was tender and swollen with limitation of motion, but was not erythematous. The right first, second, and third MTP joints were hot, erythematous, swollen, and exquisitely tender. No tenosynovitis was present.Laboratory studies revealed a hematocrit of 37 and a leukocyte count of 13,600/mmS with 81% neutrophils and 19%