Case Studies
The Case of the Parent in Pain
A Young Man with Abrupt-Onset Arthritis
By Paul Waytz, M.D.
Late one summer afternoon, I was asked to see a 31-year-old man who had been hospitalized for pain. Five days prior to admission, he began having widespread joint and muscular symptoms that progressed to the point that he could barely get out of bed or perform simple tasks. He went to the emergency room twice and was given analgesics before he was eventually admitted. He had significant stiffness, swelling in the small and large joints, and weakness. However, his joints were neither red nor warm, he did not have a fever or chills, he hadn’t traveled recently, nor had he been bitten by an insect.
Three days before the onset of symptoms, he noticed a rash on his chest and back that resolved without specific treatment and thought it was heat rash. The man had no history of rashes or photosensitivity. A detailed rheumatologic review and general review of symptoms was completely normal.
Examination revealed a patient who was uncomfortable, appeared to be nontoxic, and was in no acute distress. He had synovitis of the PIP and MCP joints, both wrists, and both knees. He did not have muscle tenderness, but his strength could not adequately be assessed. I found mild submandibular adenopathy. The remainder of the examination was normal. Specifically, there were no cutaneous, mucosal, or nail abnormalities.
Laboratory studies were obtained just prior to and during admission. They included CBC, ESR, screening chemistries, hepatic and renal functions, CK, aldolase, uric acid, streptococcal studies, mono spot, HIV, Lyme titer, blood cultures, hepatitis screens, VDRL, and FANA. All were normal or negative. A subsequent HLA-B27 returned negative. Rheumatoid factor was 28 and CRP 26.4.
While taking the patient’s history, I asked whether he had children and whether they had been sick. He told me he had a 4-year-old daughter and an 8-year-old son. The daughter had been ill and was diagnosed with fifth disease (parvovirus B19), which she contracted at school. She had a fever for 2 days, then a bright red rash on her cheeks.
I diagnosed the man as having abrupt-onset polyarthritis. Given the clinical picture and history of exposure to fifth disease 2 weeks prior to the appearance of his symptoms, there was a high likelihood of parvovirus B19 arthritis. Subsequent laboratory testing revealed significant elevation of IgM and less elevation of IgG parvovirus titers, consistent with recent exposure.
The man was started on 20 mg of prednisone daily and noticed improvement of all symptoms within a short period of time. Synovitis resolved, the prednisone was tapered following discharge, and there was no further recurrence.
Parvovirus B19 is spread by respiratory droplets. It most often causes a short-lived illness in children. Most children are contagious prior to the onset of symptoms, and there is a high secondary attack rate for both household and school contacts. The incubation period is 10 to 14 days. Mini-epidemics are common.1-4 Parvovirus B19 may invade red cells in the marrow, which can create severe problems for patients with hemoglobinopathies. Previously uninfected pregnant women are at risk for hydrops fetalis and potential miscarriage if exposed during the first trimester.
Although 50% of adults demonstrate immunity to parvovirus B19, arthritis induced by the virus is much more common in adults than children. However, the characteristic “slapped cheek” rash is rare in adults; an atypical and potentially longer-lasting rash may occur on the extremities and torso but cutaneous features are usually absent.
Parvovirus arthritis is a symmetric polyarthritis resembling rheumatoid arthritis, although the onset is more abrupt than gradual. Markers of inflammation are often, but not always, elevated; however, rheumatoid factor and anti-nuclear antibodies may be falsely positive. Parvovirus IgM antibody titer rises and falls in a matter of weeks, creating a small window of opportunity for making a precise diagnosis.
Joint symptoms usually last 3 weeks and can be controlled with conservative measures. However, up to 20% of patients may demonstrate symptoms and synovitis lasting up to 6 months and require modest doses of prednisone. There is no evidence of progression to other forms of arthritis or of joint damage.
In summary, typical historical features and findings of a recent-onset polyarthritis suggest the diagnosis. Casual exposure to the virus is possible given its highly contagious nature. Laboratory evidence of elevated IgM titers confirms recent exposure. In this case, the outcome as a result of treatment was highly successful.
Paul Waytz is a rheumatologist with Arthritis Rheumatology Consultants in Edina.
References
1. Vafaie J, Schwartz RA. Parvovirus B19 infections. Int J Dermatol. 2004:43(10):747-9.
2. Corcoran A, Doyle S. Advances in the biology, diagnosis, and host-pathogen interactions of parvovirus B19. J Med Microbiol. 2004:53(pt 6):459-75.
3. Lehmann HW, von Landenberg P, Modrow S. Parvovirus B19 infection and autoimmune disease. Autoimmun Rev. 2003:2(4):218-23.
4. Young NS, Brown KE. Parvovirus B19. N Engl J Med. 2004:350(6):586-97.