Friday, December 19, 2014

A 22-year-old woman presents with diffuse arthralgias and morning stiffness in her hands, knees, and wrists.

A 22-year-old woman presents with diffuse arthralgias and morning stiffness in her hands, knees, and wrists.

Two weeks earlier, she had a self-limited febrile illness notable for a red facial rash and lacy reticular rash on her extremities. 

On examination, her bilateral wrists, metacarpophalangeal joints, and proximal interphalangeal joints are warm and slightly boggy. 

Which of the following tests is most likely to reveal her diagnosis?

A. Antinuclear antibody
B. Chlamydia trachomatis ligase chain reaction of the urine
C. Joint aspiration for crystals and culture
D. Parvovirus B19 IgM
E. Rheumatoid factor

ans :

The answer is D.  The most likely diagnosis based on the patient’s antecedent illness with a facial rash is parvovirus infection. Arthropathy is uncommon in childhood parvovirus infection but may cause a diffuse symmetric arthritis in up to 50% of adults.

This corresponds to the immune phase of illness when immunoglobulin M antibodies are developed. The arthropathy syndrome is more common in women than men. The distribution of affected joints is typically symmetric, most commonly in the small joints of the hands and less commonly the ankles, knees, and wrists. Occasionally the arthritis persists over months and can mimic rheumatoid arthritis. Rheumatoid factor can be detected in serum. Parvovirus B19V infection may trigger rheumatoid disease in some patients and has been associated with juvenile idiopathic arthritis. Reactive arthritis caused by Chlamydia spp. or a list of other bacterial pathogens tends to affect large joints such as the sacroiliac joints and spine. It is also sometimes accompanied by uveitis and urethritis. The large number of joints involved with a symmetric distribution argues against crystal or septic arthropathy. 


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