A 27-year-old woman comes to the office due to joint pain. Her symptoms began 10 days ago and consist of bilateral pain in the metacarpophalangeal joints, proximal interphalangeal joints, wrists, knees, and ankles. She describes joint stiffness lasting 10-15 minutes on awakening in the morning. The patient has also had associated fatigue and a few episodes of loose bowel movements associated with mild skin itching and patchy redness. She has no fever, weight loss, or lymphadenopathy. She has no other medical conditions and takes no medications. The patient is married and has 2 children. She works as an elementary school teacher. On examination, there is tenderness of the involved joints without swelling or redness. The remainder of the physical examination is unremarkable. Which of the following is most likely elevated in this patient?

Question

A 27-year-old woman comes to the office due to joint pain.  Her symptoms began 10 days ago and consist of bilateral pain in the metacarpophalangeal joints, proximal interphalangeal joints, wrists, knees, and ankles.  She describes joint stiffness lasting 10-15 minutes on awakening in the morning.  The patient has also had associated fatigue and a few episodes of loose bowel movements associated with mild skin itching and patchy redness.  She has no fever, weight loss, or lymphadenopathy.  She has no other medical conditions and takes no medications.  The patient is married and has 2 children.  She works as an elementary school teacher.  On examination, there is tenderness of the involved joints without swelling or redness.  The remainder of the physical examination is unremarkable.  Which of the following is most likely elevated in this patient?

Quizplus · Accepted Answer

11ec25c8_d0ea_d3ab_bc81_af89212ff346_MD0003_00 This patient's acute symmetric arthralgias most likely represent viral arthritis secondary to parvovirus B19. Parvovirus is among the most common causes of acute viral arthritis (others include hepatitis B and C, HIV, and rubella). Parvovirus infection most commonly affects adults who have frequent contact with children (eg, school teachers, daycare workers). Children with parvovirus infection often develop a "slapped cheek" rash as part of erythema infectiosum. Nearly 75% of adults with parvovirus infection develop a nonspecific rash, but <20% have the characteristic erythema infectiosum rash. Adults most commonly develop a polyarticular, symmetric arthritis (60% of cases) involving peripheral joints, including the hands (metacarpophalangeal [MCP], proximal interphalangeal [PIP], and wrist), knees, and ankles. Arthritis due to parvovirus B19 typically does not cause joint destruction or chronic arthritis. Other possible nonspecific findings include fever, fatigue, and diarrhea. Parvovirus B19 infection is diagnosed by detecting anti-B19 IgM antibodies in the serum, which develop within 10-15 days of infection and usually remain positive for 1-6 months. The symptoms typically resolve spontaneously in 2-3 weeks without the need for specific treatment. (Choices A and G) Anti-cyclic citrullinated peptide antibodies and rheumatoid factor are usually associated with rheumatoid arthritis (RA). RA presents with joint stiffness ≥1 hour in the morning, joint swelling on examination, and symptoms for >6 weeks. Although parvovirus can affect similar joints (eg, MCP, PIP, wrist), this patient's acute symptom onset (10 days) and absence of both joint swelling and prolonged joint stiffness in the morning make RA less likely. In addition, RA would be unusual at age 27. (Choices B and C) Antinuclear antibody testing is highly sensitive for systemic lupus erythematosus (SLE); anti-double-stranded DNA antibodies are highly specific for the diagnosis. There is significant overlap in the appearance of parvovirus-related arthritis and the arthritis of SLE, but SLE most often causes chronic rather than acute arthritis. Other findings of SLE include malar or discoid rash, hematologic abnormalities (eg, anemia), renal disease, fever, malaise, and weight loss. This patient's short duration of joint pain and absence of other findings make SLE unlikely. (Choice E) Anti-streptolysin titers are positive in patients with acute rheumatic fever and indicate recent streptococcal infection. Typical findings include migratory polyarthritis, pancarditis, Sydenham's chorea, erythema marginatum, and subcutaneous nodules. However, the arthritis of rheumatic fever is usually migratory and initially affects lower-extremity joints. (Choice F) Mixed cryoglobulinemia is usually associated with chronic hepatitis C and can cause arthralgias. The arthralgias of mixed cryoglobulinemia usually occur in association with a chronic vasculitic syndrome characterized by palpable purpura, lymphadenopathy, nephropathy, and neuropathy. Educational objective: Parvovirus B19 can cause an acute symmetric arthritis of the hands (metacarpophalangeal, proximal interphalangeal, and wrist), knees, and ankle joints. The diagnosis can be confirmed with anti-parvovirus B19 IgM. The syndrome is usually self-limited and does not require specific treatment. References: Parvovirus B19: its role in chronic arthritis. (http://www.ncbi.nlm.nih.gov/pubmed/19480999)

A 27-Year-Old Woman Comes to the Office Due to Joint