Arthropathy due to parvovirus B19 infection in an adult

A 32-year-old woman presented to our emergency department 2 days after the onset of bilateral hand swelling. Two weeks earlier, her 8-year-old son had had an erythematous rash on both cheeks. A week after her son’s onset of symptoms, she experienced a transient fever without other symptoms. One week later, she developed pain in her hands, wrists, and knee joints. She was uncertain of her immunization history. She took no medications, was otherwise healthy, and had an allergy to nonsteroidal anti-inflammatory drugs (NSAIDs). Her vital signs were normal. The dorsal aspects of her hands were erythematous, with swelling and tenderness most prominent in the proximal interphalangeal and metacarpophalangeal joints, leaving her unable to fully clench her hands (Figure 1A and 1B). We observed a faint erythematous rash over her trunk and thighs. Investigations showed her aspartate transaminase level was 40 (normal 13–30) U/L, alanine aminotransferase 38 (normal 7–23) U/L, lactate dehydrogenase 370 (normal 124–222) U/L, and C-reactive protein 0.55 (normal < 0.15) mg/dL. Our differential diagnosis included parvovirus B19 arthropathy, given the description of her son’s rash, and her parvovirus B19–specific immunoglobulin M antibodies were positive (13.1 [normal < 0.80]), confirming our diagnosis. We managed the patient with supportive care, including acetaminophen. Her symptoms resolved within 1 month (Appendix 1, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.250395/tab-related-content).

Figure 1:

(A) Edema on the dorsum of both hands of a 32-year-old woman at the initial presentation. (B) Photograph showing limited hand-clenching at the initial presentation.

Arthropathy is seen in about 60% of adolescents and adults with acute parvovirus B19 infection, whereas the classic “slapped cheek rash” is uncommon. Symmetric, polyarticular arthralgias or inflammatory arthritis predominantly affect the proximal interphalangeal and metacarpophalangeal joints, and less commonly the knee, wrist, and ankle.¹ Symptoms usually resolve within 3 weeks. About 20% of patients have persistent symptoms for months or even years,¹ but destructive arthropathies are rare.² The risks of both arthropathy and prolonged symptoms are higher in females.¹ The differential diagnosis of acute-onset arthropathy includes early rheumatoid arthritis, systemic lupus erythematosus, and other viral arthritides. ¹ Treatment is supportive, and NSAIDs are usually effective in symptom management.³

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