Table 4.
COVID-19-associated arthritis with onset >1 week after COVID-19 initial manifestations
| Study, country | N, gender, age (years) | COVID-19 symptoms | Time between onset of COVID-19 and onset of articular symptoms (SARS-CoV-2 diagnostic test) | Type of arthritis (and EA involvement) | Blood tests (included immunology) | Serologies | Arthrocentesis | Treatment for COVID-19 | Treatment for arthritis | Last assessment and chronicity |
| Cincinelli et al,17 Italy | 1, male, 27 | Mild body temperature elevation (up to 37.3°C), influenza-like symptoms and mild, bilateral conjunctival injection | 2 weeks (nasopharyngeal swab RT-PCR) | Monarthritis (first MCP) | NA | NA | Not done | NA | NSAIDs and paracetamol without resolution and then PDN 10 mg/day | Absence of pain or range of motion limitation and minimal residual swelling of the affected joint |
| Coath, et al,20 UK | 1, male, 53 | Fever, night sweats, malaise, 2 kg weight loss and loss of sense of smell | Short period but not specified (no swab was obtained; symptoms were highly suggestive of COVID-19 and subsequent SARS-CoV-2 antibody test was positive) |
Bilateral sacroiliitis and arthritis of left first costovertebral and costotransverse joints | Positive HLA-B27 | NA | Not done | NA | NSAIDs and MPD 120 mg intramuscular | Asymptomatic after 4–5 months |
| Danssaert et al, USA 38 |
1, female, 37 | Cough, congestion, fevers, chills and myalgia | 12 days after testing positive for SARS-CoV-2 | Extensor tendinitis (second, third and fourth compartments of right hand) | RF negative and positive ANA (speckled pattern); UA normal |
Lyme serology negative | Not done | NA | Initially, hydromorphone intramuscular, oxycodone and lidocaine patch; subsequently, NSAID gel, gabapentin and oral hydromorphone; wrist splint, tramadol and occupational therapy for wrist tendinitis | Tenderness of the dorsal aspect of the wrist and hand |
| De Stefano L et al21, Italy | 1, male, 30s | Arthromyalgia, fatigue, diarrhoea and anosmia | 40 days after COVID-19 (nasopharyngeal swab RT-PCR) | Monarthritis (elbow) and psoriasis lesions | ANA, ENA, RF, ACPA, HLA-B27 negative | NA | Negative for SARS- CoV-2 RNA on RT-PCR and no crystals detected | Symptomatic treatment | NSAIDs | Arthritis completely resolved |
| Di Carlo et al22, Italy | 1, male, 55 | Fever | 37 days (nasopharyngeal swab RT-PCR) | Monarthritis (ankle) | HLA-B27 negative | U. urealyticum, M. hominis and C. trachomatis in the genitourinary system and enterobacteriaceae (C. jejuni, S. flexneri, Y. enterocolitica, C. difficile, Salmonella spp) were negative | It was not possible to aspirate the synovial fluid | NA | MPD 4 mg/day | Asymptomatic on follow-up |
| Dutta et al15, India | 1, male, 14 | Mild symptoms | 3 weeks after COVID-19 (nasopharyngeal swab RT-PCR) | Polyarthritis (right elbow, bilateral knees and ankles) | ACPA, HLA-B27, ASO, ANA negative | HIV and mycoplasma negative | NA | Conservative treatment | NSAIDs, intravenous MPD at 2 mg/kg/day, PDN | Asymptomatic on follow-up |
| Fragata et al,34 Portugal | 1, female, 41 | Myalgias, fatigue, coryza and loss of smell and taste and low fever (38°C) | 4 weeks after COVID-19 symptoms (nasopharyngeal and oropharyngeal swab RT-PCR) | Polyarthritis (PIP, DIP and MCP joints) | ANA, anti-dsDNA, RF ACPA, ENA negative; normal UA | Echoviruses, parvovirus B19, HIV 1 and 2, HBV and HCV were negative | Not done | Symptomatic treatment | NSAIDs (ibuprofen 1200 mg/day), 5 days of PDN 5 mg/day | No joint complaints or new inflammatory signs at 3-month follow-up |
| Gasparotto et al,23 Italy | 1, male, 60 | Hyperpyrexia, headache, asthenia and dyspnoea; interstitial pneumonia | 32 days after diagnosis of COVID-19 (nasopharyngeal swab RT-PCR) | Oligoarthritis (right ankle and knee) | RF, ACPA, ANA, ENA and HLA-B27 were negative | Urine and blood cultures were negative; urethral swab and stool culture did not show evidence of bacterial infection | 20 cc of a cloudy, yellow and highly inflammatory synovial fluid with 20 000/mm3 WBCs of which 90% polymorphonucleates and 10% monocytes; no crystals were detected; negative cultures | Azithromycin, ceftriaxone, HCQ 400 mg/day, anticoagulation, low-flow oxygen; underwent nasotracheal intubation and received broad-spectrum antibiotics, antimycotic prophylaxis, continuous diuretic infusion, anticoagulants, noradrenalin | Ibuprofen 600 mg | Asymptomatic on follow-up (up to 6 months after discontinuation of therapy) |
| Mukarram et al 46 Pakistan | 1, male, 34 | Low-grade fever, dry cough, severe fatigue/lethargy, loss of appetite and ageusia | 14 days (nasopharyngeal swab RT-PCR) | Monarthritis (knee) | NA | NA | NA | Azithromycin (for 5 days), zinc and multivitamins | NSAIDs and intra-articular steroid injection | Arthritis resolved completely within 10 days |
| Gibson et al,25 UK | 1, male, 37 | Fever, non-productive cough and fatigue | 5 weeks after COVID-19 (nasopharyngeal swab RT-PCR) | Symmetrical polyarthritis (wrists, PIP) and Achilles tendinitis | RF, ACPA, ANA/ENA and HLA-B27 negative | NA | NA | NA | PDN 20 mg daily and NSAIDs | In remission with normal inflammatory markers at follow-up |
| Hønge et al,26 Denmark |
1, male, 53 | Fatigue, shortness of breath and fever up to 40°C, hypoxia <90% despite oxygen therapy | 16 days after infection (oropharyngeal swab RT-PCR) | Oligoarthritis (knee and ankles) | RF, ACPA, HLA-B27, ANAs were negative | HIV negative; blood cultures negative | Polynuclear cells and a smaller number of mononuclear cells detected; no crystals detected; negative cultures | 200 mg intravenous remdesivir followed by 100 mg/day; 6 mg intravenous dexamethasone | NSAIDs (ibuprofen 400 mg orally three times per day) and PDN 25 mg/day | Arthritis resolved completely after 4 months of follow-up |
| Jali, Saudi Arabia35 | 1, female, 39 | Fever, sore throat, fatigue, generalised body pain and headache | 3 weeks (nasopharyngeal swab RT-PCR) | Polyarthritis (PIPs and DIPs) | RF, ACPA, ANA negative | Hepatitis and HIV negative | NA | NA | NSAID | Remission |
| Kocyigit et al,32 Turkey | 1, female, 53 | Headache and ageusia, cough, sputum and dyspnoea | 41 days after infection (nasopharyngeal swab RT-PCR) | Monarthritis (knee) | RF, ACPA, HLA-B27, ANA were negative; normal UA |
NA | 12 mL cloudy-yellow synovial fluid with 18 000/mm3 WBC of which 80% polymorphonucleates; negative cultures and no crystals detected | Favipiravir, HCQ, azithromycin, anticoagulantion and oxygen therapy | Diclofenac 150 mg/day | Arthritis not observed in follow-up examinations |
| Ono et al, 27 Japan | 1, male, 50s | Fever with chills and severe fatigue; mildly hypoxic | 21 days (nasopharyngeal swab RT-PCR) | Oligoarthritis (ankles) and Achilles enthesitis | RF, ACPA, ANA and HLA-B27 were negative | Syphilis, HIV, ASO, Mycoplasma, C. pneumoniae negative; gonococcal and C. trachomatis urine PCR negative | Mild inflammatory fluid without crystals; cultures of synovial fluid was also negative | Favipiravir, supportive care with empiric cefepime and vancomycin; intubation | NSAIDs and intra-articular corticosteroid injection | Moderate improvement |
| Ouedraogo et al,28 2USA | 1, male, 45 | Productive cough and fever, multiorgan failure | 48 days (nasopharyngeal swab RT-PCR) | Monarthritis (left knee) | RF, ACPA were negative | Gonorrhoea, Chlamydia, HBV, C. difficile and HIV, CMV, EBV, enterovirus, parvovirus B19, and T. pallidum were negative | 11 000/mm3 WBC with 94% polymorphonuclears, no crystals and negative cultures | Azithromycin, ceftriaxone, HCQ and tocilizumab; intubation, extracorporeal membrane oxygenation and dyalisis | Oral corticosteroids | Significant improvement |
| Parisi et al33, Italy | 1, female, 58 | Arthralgia, fever, cough, nausea, diarrhoea and dysgeusia | 25 days (nasopharyngeal swab RT-PCR) | Monarthritis (ankle) and Achilles tendinitis | RF, ACPA, ANA, ENA and dsDNA negative | NA | NA | Paracetamol | Ibuprofen 600 mg twice a day | Synovitis still present 30 days after treatment initiation |
| Santacruz et al,39 Colombia | 1, female, 30 | Odynophagia, anosmia, dysgeusia, bilateral conjunctivitis, fever of 38.5°C and dyspnoea | 1 month (positive antigen test) | Dactylitis of left fourth toe and extra-articular findings (conjunctivitis, oral lesions, palatal erosion, blennorrhagic keratoderma, subungual hyperkeratosis and onycholysis, circinate vulvitis) | HLA-B27 and HLA-B15 positive | M. pneumoniae, C. trachomatis negative; VDRL and HIV negative | NA | Dexamethasone | PDN 15 mg/day | Remission |
| Saricaoglu et al,19 Turkey | 1, male, 73 | Fever, weakness and dry cough | 22 days (nasopharyngeal and oropharyngeal swab RT-PCR) | Polyarthritis (MTP, PIPs and DIPs) | ACPA and RF negative; normal UA | NA | NA | HCQ, azithromycin and ceftriaxone | NSAIDs | Completely resolved with NSAID therapy |
| Schenker et al,30 Germany | 1, female, 65 | Respiratory symptoms, fever and shortness of breath; generalised myalgia and back pain | 10 days (tested positive but test not specified) | Symmetric polyarthritis of ankles, wrists and knee joints | HLA-B27 positive; all auto-antibody tests were negative | Negative (not specified which ones) | NA | NA | Prednisolone | Regressed after starting prednisolone |
| Shokraee et al,36 Iran | 1, female, 58 | Unproductive cough, shortness of breath and extreme fatigue | 15 days (nasopharyngeal swab RT-PCR) | Sacroiliitis and right hip arthritis | NA | Brucellosis and tuberculosis were negative | NA | Interferon-β1, dexamethasone, ceftriaxone, enoxaparin and nortriptyline | 100 mg indomethacin twice a day and 80 mg intramuscular depot steroid | In remission after 14 days |
| Sidhu et al31, UK | 1, female, 31 | Fever, cough, malaise, weight loss, acute swelling of lips, dysphagia and widespread urticarial rash | 10 days (nasopharyngeal swab RT-PCR) | Polyarthritis (wrists, elbows, knees and hands) | ANA, ANCA, IgM-RF, ACPA and HLA-B27 were all negative | Urine and blood cultures were negative | NA | Not reported | PDN 30 mg/day | In remission after 2 months |
| Sureja et al18, India | 1, female, 27 | Fever and body aches | Two weeks after COVID-19 (nasopharyngeal swab RT-PCR) | Polyarthritis (bilateral knee, ankle and midfoot joints and mild arthritis of the wrist, MCP and PIP joints) | RF positive (low titter); ACPA, ANA and HLA-B27 negative | NA | NA | 1 mg/kg CS in the form of oral MPD and favipiravir | CS 0.25 mg/kg tapered and stopped over 3 weeks, NSAIDs and oral opioids | Improved significantly (at 4-week follow-up) |
| Yokogawa N et al,29 Japan | 1, male, 57 | Cough, fever and malaise | 15 days after COVID-19 (nasopharyngeal swab RT-PCR) | Monarthritis (right knee) | RF and ACPA negative | Negative HBV surface antigen, HCV and HIV | Negative for SARS- CoV-2 RNA on RT- PCR and free from crystals | Symptomatic treatment | Without treatment | Resolved |
| Colatutto et al,37 Italy | 1, female, 58 | Cough | Within 1 month (nasopharyngeal swab RT-PCR) | Sacroiliitis | ANA, RF and HLA-B27 negative | NA | NA | HCQ and azithromycin | NSAIDs | Mild low back pain |
| 1, female, 53 | Cough | Within 1 month (nasopharyngeal swab RT-PCR) | Sacroiliitis | ANA and RF negative | NA | NA | HCQ and azithromycin | NSAIDs | Mechanical low back pain | |
| Salvatierra et al16, Spain | 1, female, 16 | Anosmia, ageusia, odynophagia and fever | 11 days (SARS-CoV-2 serology positive for IgG and IgM) | Dactylitis (left second, fourth and fifth toes) | ANA, RF and HLA-B27 negative | NA | NA | NA | Naproxen 500 mg twice daily for 5 days | Resolved |
ACPA, anticitrullinated protein antibodies; ANA, antinuclear antibodies; ASO, antistreptolysin O; C. difficile, Clostridium difficile; C. jejuni, Campylobacter jejuni; CMV, citomegalovirus; C. pneumoniae, Chlamydia pneumoniae; CS, corticosteroids; C. trachomatis, Chlamydia trachomatis; DIP, distal interphalangeal; ds-DNA, double-stranded DNA; EA, extra-articular; EBV, Epstein-Barr virus; ENA, extractable nuclear antigen; HBV, hepatitis B virus; HCQ, hydroxychloroquine; HCV, hepatitis C virus; HLA, human leucocyte antigen; MCP, metacarpophalangeal; M. hominis, Mycoplasma hominis; MPD, methylprednisolone; M. pneumoniae, Mycoplasma pneumoniae; MTP, metatarsophalangeal; N, number of patients; NA, not available; NSAID, non-steroid anti-inflammatory drug; PDN, prednisolone; PIP, proximal interphalangeal; RF, rheumatoid factor; RT-PCR, real-time PCR ; S. flexneri, Shighella flexneri; UA, uric acid; U. urealyticum, Ureaplasma urealyticum; VDRL, venereal disease research laboratory; WBC, white blood cell; Y. enterocolitica, Yersinia enterocolitica.