By Karla Gale
NEW YORK (Reuters Health) – Chronic hepatitis C virus (HCV) infection with mixed cryoglobulinemia is often accompanied by rheumatologic symptoms, Italian investigators report. They recommend that HCV be considered in the differential diagnosis of rheumatologic symptoms of unknown origin.
Dr. Nicola Leone, of Molinette Hospital in Turin, and colleagues found that of 114 patients with HCV and cryoglobulinemia, 51 (44.7%) had rheumatological symptoms. These often comprised "an intermittent, generally nonerosive oligoarthritis involving large and medium-sized joints," the investigators write in the Journal of Medical Virology for February.
Seronegative arthritis was present in 16.6% of subjects, carpal tunnel syndrome in 6%, Raynaud's phenomenon in 3.5%, and symptoms of Sjogren's syndrome in 8.7%. Rheumatoid arthritis meeting the American College of Rheumatology criteria was diagnosed in 9.6%. Except for Raynaud's phenomenon, all manifestations were more common in patients whose HCV infection had progressed to cirrhosis.
In an interview with Reuters Health, Dr. Leonard Calabrese, Chief of Clinical Immunology at the Cleveland Clinic in Ohio, commented that "while the percentages may differ, we believe that HCV represents a major cause of undetected rheumatologic symptomatology, and is now a major focus of education for rheumatologists."
He noted that such symptoms as painful joints, muscle aches, fatigability and vasculitis can be sentinel events in patients with HCV. "Mixed cryoglobulinemia is relatively rare," he added, and it has been only in the past 10 years that clinicians have recognized that "virtually all cases are associated with HCV." Cryoglobulinemia presents with a vasculitic skin rash, skin ulcers, neuropathies, renal problem, and the aches and pains associated with arthritis.
"There are a large number people with bona fide rheumatoid arthritis who have HCV," Dr. Calabrese stated. "These patients pose a particular challenge for therapy since so many of the drugs used to treat the arthritis are metabolized by the liver." He recommends that drugs such as methotrexate not be initiated without screening patients for HCV first.
In addition, interferon used to treat HCV can itself cause arthritis, neuropathy, and delayed wound healing, he pointed out. "HCV and rheumatological symptoms present a very complex matrix of decision-making," he emphasized, which should be done by those knowledgeable in both areas.