A 35-year-old woman comes to the office with symmetric swelling and pain of her proximal interphalangeal, wrist, and knee joints. She reports that her 5-year-old son was seen by his pediatrician last week for a facial rash and fever. The patient's family history is significant for diabetes mellitus and gout in her father and rheumatoid arthritis in her mother. Her serum rheumatoid factor is negative. Conservative management with nonsteroidal anti-inflammatory drugs is recommended. The patient returns for follow-up 4 weeks later and reports that she discontinued the medication after 2 weeks due to gastrointestinal upset. However, her pain and swelling have decreased significantly. Which of the following is the most likely diagnosis?

Question

A 35-year-old woman comes to the office with symmetric swelling and pain of her proximal interphalangeal, wrist, and knee joints.  She reports that her 5-year-old son was seen by his pediatrician last week for a facial rash and fever.  The patient's family history is significant for diabetes mellitus and gout in her father and rheumatoid arthritis in her mother.  Her serum rheumatoid factor is negative.  Conservative management with nonsteroidal anti-inflammatory drugs is recommended.  The patient returns for follow-up 4 weeks later and reports that she discontinued the medication after 2 weeks due to gastrointestinal upset.  However, her pain and swelling have decreased significantly.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec160b_3a63_72c2_9249_957dde0f5ede_MD0001_00 This patient and her child have typical features of parvovirus B19 infection. Parvovirus is a small, single-stranded DNA virus with respiratory, congenital, or hematogenous transmission. Initial infection may cause a nonspecific viral syndrome with headache, coryza, and gastrointestinal symptoms. Parvovirus may subsequently cause 2 primary syndromes in immunocompetent patients: The initial nonspecific period of infection is associated with heavy viremia and viral shedding. By contrast, erythema infectiosum and acute arthropathy signify an active immune response with formation of immune complexes and minimal or undetectable viremia. These patients have much reduced infectivity. (Choice A) Gout causes acute monoarthritis, usually affecting the lower extremity (great toe, ankle, knee). (Choice B) Herpes simplex virus (HSV) infection causes oral or genital lesions characterized by grouped vesicles on an erythematous base. HSV does not usually cause arthritis. (Choice C) Lyme disease causes a characteristic annular erythematous rash (erythema chronicum migrans). Asymmetric arthritis may develop in late or chronic Lyme disease. (Choice E) In rheumatic fever, there may be migratory pain and swelling of the large joints in addition to fever, carditis, choreiform movements, and erythema marginatum. Rheumatic fever develops following streptococcal pharyngitis. (Choice F) Rheumatoid arthritis may cause an acute polyarthropathy that is initially similar to parvovirus arthritis. The symptoms may be temporarily relieved with nonsteroidal anti-inflammatory drugs but would not resolve as promptly as they did in this patient. In addition, serum rheumatoid factor is usually, although not always, positive. (Choice G) The typical initial onset of systemic lupus erythematosus is characterized by malaise, weight loss, malar facial rash, and arthralgias. Educational objective: Parvovirus B19 causes erythema infectiosum (fifth disease) in children and arthritis in adults. Parvovirus arthritis can mimic rheumatoid arthritis but is usually self-resolving. __________ References: Human parvovirus B19: a review. (http://www.ncbi.nlm.nih.gov/pubmed/25283854)

A 35-Year-Old Woman Comes to the Office with Symmetric Swelling