A 24-year-old woman comes to the office with a 4-week history of joint pain. She has had moderate, achy pain and swelling in multiple metacarpophalangeal joints of both hands, with lesser pain in the wrists, knees, and elbows. In addition, the patient experienced intermittent fevers at the onset of her pain, but has been afebrile since then. She has had relief of her symptoms with over-the-counter ibuprofen, but in the week since she scheduled her appointment, she has not required medication as the pain has resolved. The patient is married and has 2 children. Vital signs are normal. Examination shows normal range of motion in all joints tested, with no redness, warmth, or swelling in any hand joints. X-rays of the hands are normal. Which of the following is the most likely diagnosis?

Question

A 24-year-old woman comes to the office with a 4-week history of joint pain.  She has had moderate, achy pain and swelling in multiple metacarpophalangeal joints of both hands, with lesser pain in the wrists, knees, and elbows.  In addition, the patient experienced intermittent fevers at the onset of her pain, but has been afebrile since then.  She has had relief of her symptoms with over-the-counter ibuprofen, but in the week since she scheduled her appointment, she has not required medication as the pain has resolved.  The patient is married and has 2 children.  Vital signs are normal.  Examination shows normal range of motion in all joints tested, with no redness, warmth, or swelling in any hand joints.  X-rays of the hands are normal.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d122_84ba_bc81_e7eab4d38e2c_MD0003_00 This patient has symmetric polyarticular arthritis with a brief, self-limited course. In light of her exposure to young children, this is likely viral arthritis due to parvovirus B19. Viral arthritis is often associated with joint swelling and tenderness, but objective findings may be subtle or absent. Whereas children with parvovirus B19 typically present with the characteristic "slapped cheek" rash, adults are more likely to develop a nonspecific morbilliform exanthem and may have no skin manifestations at all. A similar arthritis may also be seen with HIV, mumps, rubella, and other viruses. rash morbilliform exanthem The arthritis of parvovirus B19 may resemble early rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE), and may be associated with a weakly positive rheumatoid factor or antinuclear antibody titer. However, RA and SLE are significantly less common, usually produce more obvious synovitis, and typically follow a more chronic, protracted course (Choices F and H). In addition, SLE is usually associated with manifestations in multiple systems (eg, malar rash, oral ulcers, serositis) and is less likely to resolve spontaneously. If there is doubt regarding the diagnosis, parvovirus B19 infection can be confirmed with assay for anti-parvovirus IgM or nucleic acid amplification testing. (Choices A and C) Crystalline arthritis (ie, gout, pseudogout) and purulent gonococcal arthritis cause acute, inflammatory monoarthritis. Disseminated gonococcal infection can also present as chronic polyarticular arthralgias but is asymmetric, often favors large joints, and is associated with tenosynovitis and pustular skin lesions. (Choice B) Fibromyalgia is characterized by chronic widespread pain, often with fatigue and affective symptoms. Localized joint swelling is not seen. (Choice D) Untreated Lyme disease can lead to arthritis. However, symptoms are chronic and favor the large joints (eg, knee). (Choice E) Polymyalgia rheumatica causes pain and stiffness in the neck, shoulder, and hip muscles. Localized arthralgias may occur but are uncommon. Polymyalgia rheumatica occurs almost exclusively in patients age >50; this patient's age effectively rules out PMR. (Choice G) Seronegative spondyloarthropathies (eg, ankylosing spondylitis, reactive arthritis, psoriatic arthritis) are characterized by chronic asymmetric arthritis and inflammatory back pain. Educational objective: The self-limited arthritis of parvovirus B19 may resemble early rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE), and may be associated with a weakly positive rheumatoid factor or antinuclear antibody titer. However, RA and SLE are significantly less common, typically produce more obvious synovitis, and usually follow a chronic, protracted course.

A 24-Year-Old Woman Comes to the Office with a 4-Week