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LETTER TO EDITOR
Ahead of print publication  

Arthritis as a distinctive atypical clinical presentation of COVID-19


1 Department of Medicine, S.N. Medical College, Agra, Uttar Pradesh, India
2 Department of Obstetrics and Gynaecology, S.N. Medical College, Agra, Uttar Pradesh, India

Date of Submission21-Jul-2020
Date of Acceptance22-Jul-2020

Correspondence Address:
Anjana Pandey,
Department of Medicine, S.N. Medical College, Agra, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injr.injr_196_20



How to cite this URL:
Agrawal P, Garg R, Pandey A, Gautam A. Arthritis as a distinctive atypical clinical presentation of COVID-19. Indian J Rheumatol [Epub ahead of print] [cited 2020 Oct 27]. Available from: https://www.indianjrheumatol.com/preprintarticle.asp?id=297405



Dear Editor,

There are limited data for the rheumatological manifestations as the clinical presentation of COVID-19.[1] We report a case of 24-year-old male, student, presenting with complaints of sudden-onset severe pain and swelling in both wrists, elbows, knees, and ankles for 3 days. The patient also complained of morning stiffness lasting for many hours. There were no history of similar episodes in the past, no involvement of small joints of the hand, and any history suggestive of seronegative spondyloarthropathy, urinary tract infection, psoriasis, low back pain, enthesitis, uveitis, diarrhea, fever, sore throat, rashes, and oral ulcers. There was a history of close contact with his brother who was COVID-19 positive, who had recently traveled abroad to Dubai; as the patient was a potential candidate for novel coronavirus reverse transcription–polymerase chain reaction (RT-PCR) testing, it was done and came positive. The patient was admitted in isolation ward. On examination, the patient was afebrile, and vital parameters and general and systemic examination were unremarkable. The complete blood count was normal, and erythrocyte sedimentation rate westergren (WG) was 22 mm/h. Rheumatoid factor, anti-cyclic citrullinated peptide, hepatitis B virus surface antigen, anti-hepatitis C virus, and HIV were also negative. Electrocardiogram was normal. X-ray of the involved joint showed soft-tissue swelling, no bony erosions, or deformities.

Paracetamol 650 mg QID along with hydroxychloroquine (HCQ) 400 mg OD started. Pain, though reduced in intensity, not fully relieved (Visual Analog Scale [VAS] 9 to VAS 6) and swelling persisted. The patient complained of extreme morning stiffness. As no contraindication persisted, on the 3rd day, methylprednisolone 16 mg OD was added which resulted in marked improvement in the pain (VAS 6 to VAS 2) and swelling. Seventh day onward, methylprednisolone was tapered to 8 mg OD, and the dosage of paracetamol was reduced to twice in a day. By the 10th day, as the patient was entirely asymptomatic, all the ongoing drugs were withdrawn. After 12 days of admission, the repeat RT-PCR evaluation of the nasopharyngeal swab, on two consecutive occasions, 24 h apart, was negative. As per the discharge criteria by the Indian Council of Medical Research, the patient was discharged on the 15th day of admission on HCQ 400 mg OD. Arthritis as an atypical presentation should be borne in mind for the suspicion of COVID-19. This is perhaps the first case of COVID-19 which presented with acute-onset seronegative symmetrical large joint inflammatory polyarthritis which did not progress to any other COVID symptoms including respiratory difficulty and pneumonia, unlike a case reported which was published earlier with arthralgia as initial manifestation which later progressed to respiratory complications.[2] We emphasize that the rheumatological manifestations of COVID-19 could be a signal for suspicion for an early detection and early initiation of adequate supportive measures. It is important to carefully acquire the epidemiological, travel, and contact history for COVID in all the patients who are coming with acute-onset arthritis. Such atypical presentation also poses a risk to the health-care providers, and hence, we emphasize upon a full personal protection equipment while evaluating and managing even the unsuspected patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.  Back to cited text no. 1
    
2.
Joob B, Wiwanitkit V. Arthralgia as an initial presentation of COVID-19: observation. Rheumatol Int 2020;40:823.  Back to cited text no. 2
    




 

 
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