A 29-year-old woman comes to the office due to severe joint pain in her hands, wrists, and ankles for a week. The pain is so severe that she is unable to perform her daily activities, and taking ibuprofen provides only partial relief. She has no prior medical conditions but developed high fever and diffuse rash during a trip to Puerto Rico 2 weeks ago. Evaluation at a local medical facility was negative for malaria, and her symptoms improved spontaneously after several days. She does not use tobacco, alcohol, or illicit drugs and is in a monogamous relationship with her husband. Temperature is 37 C (98.6 F), blood pressure is 122/70 mm Hg, and pulse is 86/min. Physical examination shows pink, moist oropharyngeal mucosa; no rash; clear lungs; normal heart sounds; and no abdominal organomegaly. There is periarticular swelling and tenderness of the wrists, ankles, and interphalangeal joints of her hands. Range of motion in these joints is decreased due to pain. Laboratory testing reveals lymphopenia. Which of the following is the most likely cause of this patient's joint pain?

Question

A 29-year-old woman comes to the office due to severe joint pain in her hands, wrists, and ankles for a week.  The pain is so severe that she is unable to perform her daily activities, and taking ibuprofen provides only partial relief.  She has no prior medical conditions but developed high fever and diffuse rash during a trip to Puerto Rico 2 weeks ago.  Evaluation at a local medical facility was negative for malaria, and her symptoms improved spontaneously after several days.  She does not use tobacco, alcohol, or illicit drugs and is in a monogamous relationship with her husband.  Temperature is 37 C (98.6 F), blood pressure is 122/70 mm Hg, and pulse is 86/min.  Physical examination shows pink, moist oropharyngeal mucosa; no rash; clear lungs; normal heart sounds; and no abdominal organomegaly.  There is periarticular swelling and tenderness of the wrists, ankles, and interphalangeal joints of her hands.  Range of motion in these joints is decreased due to pain.  Laboratory testing reveals lymphopenia.  Which of the following is the most likely cause of this patient's joint pain?

Quizplus · Accepted Answer

11ec160b_3817_fc14_9249_4dce3847e925_MD0001_00 This patient's transient febrile illness and rash followed by severe polyarthritis raise strong suspicion for chikungunya, an alphavirus transmitted to humans by Aedes mosquitos during blood feeding. Outbreaks are common in tropical and subtropical climates (eg, Puerto Rico, Africa, Asia, Indian/Pacific islands) during the rainy season and may be brought back to the United States by travelers. Chikungunya means "stooped walk" because the hallmark of the disease is severe joint symptoms. Manifestations generally begin a few days after transmission with high fever, symmetric polyarticular arthralgia, and a maculopapular rash. Lymphopenia and thrombocytopenia commonly occur. Initial symptoms usually abate completely within days, but >50% of individuals develop relapsed/chronic arthralgia, polyarticular arthritis (particularly of the wrists/hands/ankles), or tenosynovitis in the following weeks or months. Because Aedes mosquitos also transmit dengue and Zika viruses, coinfection can occur. (Choice A) Gout causes recurrent, acute joint inflammation due to monosodium urate crystal deposition. However, most cases are monoarticular and occur in lower extremity joints. (Choice B) Rheumatoid arthritis is an immune-mediated disorder that causes symmetric, inflammatory polyarthritis with eventual joint destruction. Patients generally develop morning stiffness followed by joint swelling in the fingers, wrists, and toes. Given this patient's young age, febrile illness with rash during recent travel, and lymphopenia, chikungunya is more likely. (Choice C) Reactive arthritis is a rare condition that primarily occurs following a gastrointestinal (eg, Salmonella, Shigella, Campylobacter) or genital (eg, Chlamydia) bacterial infection. Manifestations typically include an asymmetric oligoarthritis that often affects the knees. This patient's symmetric polyarthritis following a febrile illness while traveling makes chikungunya far more likely. (Choice D) Lyme disease is caused by the spirochete Borrelia burgdorferi. Initial symptoms can include fever, malaise, and a spreading, annular rash (erythema migrans). Several months or years later, late manifestations such as monoarticular arthritis of the knee or asymmetric oligoarthritis can also occur. This patient's polyarticular arthritis developing a few weeks after a febrile illness makes chikungunya far more likely. Educational objective: Chikungunya is an alphavirus spread by mosquitos to humans in tropical and subtropical areas. Initial manifestations include self-limited fever, severe polyarthralgia, and rash. Relapsed or chronic arthralgias, polyarthritis (eg, wrist, fingers, ankles), or tenosynovitis occur in >50% of infected individuals. __________ References: Chikungunya infection: a re-emerging epidemic. (http://www.ncbi.nlm.nih.gov/pubmed/30047016) Chikungunya virus and the global spread of a mosquito-borne disease. (http://www.ncbi.nlm.nih.gov/pubmed/25806915)

A 29-Year-Old Woman Comes to the Office Due to Severe