the rheumatologic manifestations associated with hepatitis c virus ( hcv ) infection include arthralgia , myalgia , arthritis , vasculitis , and sicca syndrome . we presented a patient with areas of joint pain that corresponded to the regions of increased tc-99 m methylene diphosphonate ( mdp ) uptake . this demonstrates the ability of bone scan to image symptomatic joint , suggesting its potential value in the early diagnosis when compared radiography . we present a case of a 63-year - old male with chronic hepatitis c , who presented with bilateral symmetrical painful joints including hands , wrists , elbows , and shoulders in the upper limbs . in addition , he described stiffness in the regions of the right shoulders joints and swelling in the right wrist and hand regions . laboratory findings showed elevated levels of rheumatoid factor ( rf ) and normal level anti - cyclic citrullinated peptides ( ccps ) antibodies . the radiography of the upper and lower limbs did not show any abnormality [ figure 1 ] . however , the result of a subsequent bone scan including three phase of upper extremities and whole body were grossly abnormal . the images of the whole body [ figure 2 ] , blood pool , and delayed uptake [ figure 3 ] showed multiple areas of intense increased mdp uptake in the bilateral interphalangeal and metacarpophalangeal joints of hands , wrist , elbow , and shoulders and less intense increased uptake in the foot joints . there was an excellent correlation between the areas of arthritic pain and the regions of increased uptake . normal plain radiography of both painful hands anterior ( a ) and posterior ( b ) whole body bone scan demonstrated a largely symmetric polyarthropathy affecting large and small joints in the upper and lower limbs . note the diffusely increased uptake with a parallel track pattern of hypertrophic pulmonary osteoarthropathic in the femurs and tibiae on bone scan of both hands , there is increased blood pool activity ( a ) and delayed uptake ( b ) in the areas of the joint involved in addition , in whole body scan , there was hypertrophic pulmonary osteoarthropathic appearance ( affecting femora and tibiae ) . the increased osteoblastic activity in the region of thoracic vertebras was determined to be spinal bone / mainly bone - marrow metastases secondary to lung carcinoma by magnetic resonance imaging . several viruses have been associated with the development of inflammatory arthritis including hepatitis viruses ( hepatitis b virus [ hbv ] and hcv ) , hiv , parvovirus b19 , human t - cell lymphotropic virus - i , and alphaviruses . arthralgias , reported in 2083% of hcv patients , are bilateral , symmetric , nondeforming and mainly involve knees and hands , more seldom elbows , and ankles . hcv infection - related arthritis ( hcvra ) is usually distinguished in two clinical subsets : a more frequent symmetrical polyarthritis in which 5085% of patients are rf - positive , similar to rheumatoid arthritis ( ra ) but less serious , and mostly intermittent mono- and oligoarthritis that involves medium and large sized joints , mainly the ankle . the arthropathy is nonerosive / nondeforming , and no joint erosions are seen on radiographs . in 5080% of cases , rf is positive . an important point in distinguishing ra from hcvra is given by the presence of anti - ccp antibodies . other possible mechanisms include direct invasion of synovial cells by the virus , eliciting a local inflammatory response , cytokine - induced disease ( other than cryoglobulinemia ) associated with chronic , persistent hcv infection , or other mechanisms associated with reactive arthritis . an increased uptake occurs before radiographic changes are evident , which allows a more accurate estimate of disease extent and may indicate involvement in joints that are as yet asymptomatic . pathologic features of arthropathies have been translated into various patterns of findings on scintigraphic imaging modalities . the pattern of symmetric peripheral joint involvement of ra can usually be distinguished scintigraphically from that of the rheumatoid variants ( ankylosing spondylitis , psoriasis , reiter 's syndrome , etc . ) , which tend to have more central skeletal involvement and asymmetric peripheral articular uptake . we described a patient ( with normal plain radiography ) whose areas of arthritic pain exactly matched the regions of increased mdp uptake . painful upper limbs joints demonstrated intense increased uptake , whereas as painless foot joints showed less increased uptake . accurate and early diagnosis of hcvra is important so as to avoid immunosuppressive therapy , which likely may be ineffective in managing arthritis , exacerbate the viral disease , and delay effective palliative antiviral treatment . because these patients often present with confusing clinical features , there usually is a delay in the diagnosis of hcv infection , leading to a prolonged period of unsuccessful therapeutic trials . although this arthritis may be difficult to distinguish from other common chronic arthropathies , most notably ra , it is important to consider this arthropathy in the differential diagnosis of every newly presenting oligo- or polyarthritis . the patient was also tested for some other causes of polyarthritis ; hbv , hiv , and lupus psoriasis at the time of further diagnosis , and the laboratory findings were negative . because of significant differences in treatment strategies between ra and hcv arthropathy , future research efforts should focus on clarifying diagnostic differences between hcvra and other arthropathies . in larger patient groups with hcvra and other virus - related arthritis , further studies are needed both to assess scintigraphic uptake patterns for distinguishing than other arthropathies and to evaluate treatment response .
a symptomatic joint involvement and arthralgia are frequent in patients with chronic hepatitis c virus ( hcv ) infection . 
 however , hcv infection - related arthritis ( hcvra ) affects up to 4 - 11% of the subjects suffering from disease . 
 we reported a patient with hcvra presented with the commonly accepted diagnostic clinical signs and laboratory parameters . 
 the painful joints distinctly demonstrated increased uptake of tc-99 m methylene diphosphonate in scintigraphy and normal findings in radiography .