A 32-year-old woman comes to the physician because of hand pain and swelling that lasts several hours every morning. She has not felt well since "getting the flu" two weeks ago from her two children (ages 4 and 6). She initially had a sore throat and fever without rash, cough, dysuria, or diarrhea. She works as a flight attendant and travels extensively, but has been on medical leave for the past two weeks due to her illness. She is in a monogamous relationship and uses a barrier method for contraception. She does not smoke, but she drinks alcohol occasionally.
Her vital signs are within normal limits. There are no skin rashes. Oropharyngeal examination shows mild tonsillar swelling and normal appearing pharyngeal mucosa. Several 0.5 cm non-tender lymph nodes are palpable in the anterior cervical region. Auscultation of the heart and lungs is normal. There is no hepatosplenomegaly. The small joints of her hands and wrists are swollen and tender. She is unable to flex or extend her wrists or make a fist due to the pain and swelling. She has normal range of motion without swelling in both knees, ankles, shoulders, and feet.
Laboratory results are as follows:

Which of the following is the most likely diagnosis?

Question

A 32-year-old woman comes to the physician because of hand pain and swelling that lasts several hours every morning.  She has not felt well since "getting the flu" two weeks ago from her two children (ages 4 and 6).  She initially had a sore throat and fever without rash, cough, dysuria, or diarrhea.  She works as a flight attendant and travels extensively, but has been on medical leave for the past two weeks due to her illness.  She is in a monogamous relationship and uses a barrier method for contraception.  She does not smoke, but she drinks alcohol occasionally.
Her vital signs are within normal limits.  There are no skin rashes.  Oropharyngeal examination shows mild tonsillar swelling and normal appearing pharyngeal mucosa.  Several 0.5 cm non-tender lymph nodes are palpable in the anterior cervical region.  Auscultation of the heart and lungs is normal.  There is no hepatosplenomegaly.  The small joints of her hands and wrists are swollen and tender.  She is unable to flex or extend her wrists or make a fist due to the pain and swelling.  She has normal range of motion without swelling in both knees, ankles, shoulders, and feet.
Laboratory results are as follows:

Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec193a_9921_80c3_853d_3bc60072c2c8_MD0002_00 This patient's presentation is consistent with likely parvovirus infection. The classic "slapped cheek" rash is less common in adults than children. Adults usually present with flu-like symptoms 5-10 days after exposure followed by acute symmetrical arthralgias/arthritis (e.g., hands/wrists) that can resemble rheumatoid arthritis. Patients with preexisting hematologic disease (e.g., sickle cell) can develop a transient aplastic crisis, while immunocompromised patients can develop acute or chronic anemia due to bone marrow suppression of erythroid precursors. Patients may have a positive rheumatoid factor (RF), but rheumatoid arthritis should not be diagnosed by RF alone if symptoms are < 6 weeks in duration (Choice D). Acute infection is confirmed with parvovirus B19 IgM antibodies, which increase within the first month of illness and often become undetectable after 2-3 months. Parvovirus IgG antibodies reflect past exposure and are not diagnostic, since up to 50% of healthy people may have parvovirus IgG antibodies. Arthritis caused by parvovirus infection is self-limiting and usually resolves in 1-2 months. Treatment is mainly supportive with monitoring, since there is no currently effective vaccine or pharmacotherapy. (Choice A) Acute rheumatic fever usually presents with fever and migratory arthritis involving the large joints (e.g., knees), but it may involve the ankles and elbows as well. However, this patient does not have migratory arthritis or other major criteria (e.g., chorea, erythema marginatum, pancarditis, subcutaneous nodules) to suggest rheumatic fever. (Choice B) Infectious mononucleosis typically presents with fever, pharyngitis, lymphadenopathy, and atypical lymphocytosis. Patients can also have splenomegaly and a generalized rash, but usually do not present with the symmetric arthritis seen in this patient. (Choice E) Nearly 5-10% of healthy patients can have a positive ANA, usually at a low titer (e.g., 1:40). Parvovirus can cause a false-positive ANA, and this patient does not have other clinical symptoms (e.g., malar rash, photosensitivity) to suggest SLE. Educational objective: Adults with parvovirus B19 infection usually present with a flu-like illness 5-10 days after exposure followed by acute, symmetrical arthralgias/arthritis (e.g., hands/wrists) that can resemble rheumatoid arthritis. Immunocompromised patients and those with preexisting hematological disease can develop more serious complications (e.g., transient aplastic anemia). Diagnosis is confirmed with parvovirus B19 IgM antibodies. __________ References: Rheumatic manifestations of parvovirus B19 infection. (http://www.ncbi.nlm.nih.gov/pubmed/9606764) Parvovirus B19: its role in chronic arthritis. (http://www.ncbi.nlm.nih.gov/pubmed/19480999)

A 32-Year-Old Woman Comes to the Physician Because of Hand