Can Norovirus Infection Lead to a Postinfectious Arthritis? Report of 2 Possible Cases

Background

A variety of viruses (e. g., parvovirus B19, rubella, hepatitis B and C, adenovirus, Epstein-Barr, cytomegalovirus, varicella zoster, herpes simplex, mumps, echovirus, and coxsackievirus B virus) are known to cause a postinfectious arthritis in humans (Petty R and Tingle A. J Pediatr 1988; 113: 948–949; Phillips P. Curr Opin Rheumatol 1997; 9: 337–344). Symptoms may begin during the acute infection or within approx. 6 weeks thereafter and may persist after the initial viral infection has resolved clinically and serologically. Joint disease often affects the lower extremities and rarely lasts longer than a few months. Symptoms may be migratory, and permanent joint damage usually does not develop. Noroviruses are RNA viruses that cause a highly infectious gastroenteritis in humans (Patel M. et al. J Clin Virol 2009; 44: 1–8). In spite of the high regional incidence of norovirus infection, detailed reports of arthritis associated with norovirus infection do not exist. This might be explained by the simple notion that norovirus infection just does not cause arthritis. An alternate explanation is that most practitioners search for bacterial enteric pathogens, but not viruses, in patients with gastrointestinal symptoms and new-onset arthritis. Moreover, even though a reliable, relatively inexpensive assay with a rapid turn-around time – the reverse transcriptase polymerase chain reaction (RT-PCR) test for norovirus RNA – has been available for a few years, pediatric patients hospitalized for acute gastroenteritis are often not tested for norovirus infection. Here, we describe 2 children with acute arthritis and concomitant norovirus infection, raising the possibility that arthritis may develop in rare cases of norovirus gastroenteritis.