A 16-year-old girl comes to the office due to joint pain lasting several days. The patient says, "My hands and knees feel stiff when I wake up, and those joints are painful throughout the day." The symptoms are improving, but she still has significant discomfort with daily activities. The patient has never before had such symptoms. A mildly pruritic rash on her face, arms, and legs developed around the same time as the joint symptoms. Last week, the patient had an upper respiratory infection with fever and myalgias that resolved quickly without intervention. She has seasonal allergies for which she uses a glucocorticoid intranasal spray as needed. She does not use tobacco, alcohol, or illicit drugs. The patient is not in a relationship and has never been sexually active. Temperature is 37.2 C (99 F). She appears well and is sitting comfortably on the examination table. Cardiopulmonary examination is normal. Examination of the hands shows mild symmetric swelling of the proximal interphalangeal and metacarpophalangeal joints; there is no warmth or erythema. Bilateral knees have a full range of motion, mild tenderness to palpation, and no swelling. Strength and sensation are symmetric and intact throughout, and distal pulses are strong bilaterally. There is a faint, erythematous, reticular rash on both arms and legs.
Which of the following is the most likely diagnosis for this patient?

Question

A 16-year-old girl comes to the office due to joint pain lasting several days.  The patient says, "My hands and knees feel stiff when I wake up, and those joints are painful throughout the day."  The symptoms are improving, but she still has significant discomfort with daily activities.  The patient has never before had such symptoms.  A mildly pruritic rash on her face, arms, and legs developed around the same time as the joint symptoms.  Last week, the patient had an upper respiratory infection with fever and myalgias that resolved quickly without intervention.  She has seasonal allergies for which she uses a glucocorticoid intranasal spray as needed.  She does not use tobacco, alcohol, or illicit drugs.  The patient is not in a relationship and has never been sexually active.  Temperature is 37.2 C (99 F).  She appears well and is sitting comfortably on the examination table.  Cardiopulmonary examination is normal.  Examination of the hands shows mild symmetric swelling of the proximal interphalangeal and metacarpophalangeal joints; there is no warmth or erythema.  Bilateral knees have a full range of motion, mild tenderness to palpation, and no swelling.  Strength and sensation are symmetric and intact throughout, and distal pulses are strong bilaterally.  There is a faint, erythematous, reticular rash on both arms and legs. 
Which of the following is the most likely diagnosis for this patient?

Quizplus · Accepted Answer

Explanation: Parvovirus B19 is a common viral infection that typically presents with nonspecific flu-like symptoms (eg, fever, myalgias), followed by variable symptoms, depending on the age of the patient. Young children classically develop a "slapped cheek" malar rash (erythema infectiosum) and, rarely, arthralgias. Adolescents and adults, particularly female patients, may develop acute-onset symmetric joint pain, swelling, and stiffness in the proximal interphalangeal and metacarpophalangeal joints a week after the flu-like symptoms. As seen in this patient, a faint, erythematous, reticular rash may be present. However, most adolescents and adults do not have a rash. Diagnosis is often clinical but can be confirmed by serum serology (parvovirus B19 IgM antibodies); sampling of synovial fluid is rarely required. "slapped cheek" (Choice A) Acute rheumatic fever, which presents 2-4 weeks after group A Streptococcus pharyngitis, causes migratory polyarthritis involving the larger joints (eg, knee, elbow). Skin findings include erythema marginatum and subcutaneous nodules. erythema marginatum (Choice B) Lyme arthritis, following a tick exposure in a Lyme-endemic area, is often monoarticular (eg, knee) and associated with erythema migrans. erythema migrans (Choice C) Rheumatoid arthritis is a chronic inflammatory arthritis that commonly presents with morning stiffness in the bilateral metacarpophalangeal and proximal interphalangeal joints. The onset is insidious, and symptoms must be present for >6 weeks to establish the diagnosis. (Choice D) Systemic lupus erythematosus can present with constitutional symptoms (eg, fever, fatigue) and polyarticular arthritis. However, its onset is generally gradual, with extensive systemic involvement and skin findings such as photosensitivity and malar rash or discoid lesions, none of which is seen in this patient. systemic involvement malar rash discoid lesions Educational objective: Parvovirus B19 infection can cause viral arthritis, sometimes with a rash, following a nonspecific flu-like illness. Acute-onset pain, swelling, and stiffness of the symmetric small joints of the hands are typical. References: Viral arthritis. (http://www.ncbi.nlm.nih.gov/pubmed/27037381)

A 16-Year-Old Girl Comes to the Office Due to Joint