A 55-year-old woman comes to the office with a one-week history of pain in multiple joints. She has achy pain and stiffness in both wrists and multiple metacarpophalangeal and proximal interphalangeal joints in both hands. The patient's symptoms are worst in the morning and partially improve over 10-15 minutes of normal activity. There is no associated fever, chills, rash, or weight loss. She works in a day care center and does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. On examination, there is mild swelling with no redness or tenderness of the involved joints. Laboratory studies show normal blood counts and serum chemistries. Erythrocyte sedimentation rate is 12 mm/hr. Which of the following is the most likely diagnosis in this patient?

Question

A 55-year-old woman comes to the office with a one-week history of pain in multiple joints.  She has achy pain and stiffness in both wrists and multiple metacarpophalangeal and proximal interphalangeal joints in both hands.  The patient's symptoms are worst in the morning and partially improve over 10-15 minutes of normal activity.  There is no associated fever, chills, rash, or weight loss.  She works in a day care center and does not use tobacco, alcohol, or illicit drugs.  Vital signs are normal.  On examination, there is mild swelling with no redness or tenderness of the involved joints.  Laboratory studies show normal blood counts and serum chemistries.  Erythrocyte sedimentation rate is 12 mm/hr.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d514_5873_bc81_adc10d1b8624_MD0003_00 This patient has acute, symmetrical arthralgias with mild synovitis primarily involving the small joints of the hands. In light of her brief morning stiffness, normal erythrocyte sedimentation rate (ESR), and exposure to small children, this most likely represents viral arthritis due to parvovirus B19. Children with parvovirus often develop fever and the "slapped cheek" facial rash of erythema infectiosum. However, adults are more likely to develop joint symptoms; skin symptoms, if present, are mild and nonspecific. erythema infectiosum Parvovirus B19 is a nonenveloped, single-stranded DNA virus that primarily infects red cell precursors. Viral arthritis due to parvovirus B19 is typically polyarticular and symmetric. It is a common, self-limited condition that usually resolves within 1-2 months. The precise pathophysiology is unclear, but clinical manifestations correlate with anti-parvovirus IgM levels, which may be assayed for diagnostic purposes. Treatment is symptomatic, primarily with nonsteroidal anti-inflammatory drugs. (Choice A) Acute rheumatic fever occurs in the setting of recent streptococcal infection. The arthritis of rheumatic fever is migratory and usually first affects the joints of the lower extremities. Other characteristic features include carditis, chorea, erythema marginatum, and subcutaneous nodules. erythema marginatum (Choice B) Fibromyalgia is a chronic musculoskeletal pain syndrome that is often accompanied by fatigue, mood disorders, and insomnia. Symptoms are typically diffuse, and localized joint findings are not seen. (Choice C) Polymyalgia rheumatica is characterized by achy pain in the shoulders and hips. Joint swelling may occur but is not typical, and ESR is almost always elevated. (Choices D and E) Viral arthritis can resemble inflammatory arthritides such as rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE), but it follows a benign, self-limited course. SLE is a multisystem disorder that also causes rash, hematologic abnormalities, renal disease, fever, and weight loss. RA is associated with more pronounced joint swelling, at least 30 minutes of morning stiffness, and elevated ESR; a normal ESR (as seen in this patient) would be very uncommon in RA. Educational objective: Viral arthritis due to parvovirus B19 is characterized by acute, symmetric, small-joint arthralgias, mild joint swelling, and a benign, self-limited course. It is usually seen in adults, whereas erythema infectiosum due to parvovirus B19 is more common in children.

A 55-Year-Old Woman Comes to the Office with a One-Week