This patient's presentation of symmetric arthritis of the hands, knees, and ankles in the context of a preceding cold-like illness and papular, purpuric rash in a stocking-glove distribution is consistent with a parvovirus B19 infection.
Arthritis is a relatively uncommon manifestation of parvovirus B19 infection in children; however, the majority of adults with the infection develop arthropathy. Parvovirus B19 arthropathy is also more common in women. The distribution of arthritis is symmetric, most commonly involving PIP and MCP joints (similar to RA) in addition to knees, wrists, and ankles. The arthritis is often self-resolving within weeks but may last for months to years in some instances. The infection may also lead to development of subsequent rheumatoid arthritis; however, 6 weeks of symptoms must be present before considering this diagnosis. Differentiation of parvovirus B19 versus rheumatoid arthritis can be achieved through the presence of articular erosions in rheumatoid arthritis.
Servey et al. review the clinical presentation of parvovirus B19 infection in adult patients. In addition to acute or persistent arthropathy, parvovirus B19 also causes a papular, purpuric rash on the hands and feet ("stocking glove distribution"). Infection can also cause failure of red blood cell production, leading to potential aplastic crisis.
Franssila and Hedman discuss viral causes of arthritis. Postinfectious arthritis may occur after infection with alphaviruses, rubella, parvovirus B19, HIV, CMV, HBV, HCV, and EBV. Certain infections, including parvovirus and EBV, may initiate a chronic arthropathy that is clinically indistinguishable from rheumatoid arthritis.
Figure A is a photograph of the papular purpuric rash that occurs in parvovirus B19 infection; note, the distribution on the distal extremities (hands in this photograph). Illustration A summarizes the timeline of clinical manifestations and physiologic effects of parvovirus B19 infection. Illustration B lists the common clinical manifestations of parvovirus B19 infection; note that arthritis is more common in adult than pediatric patients.
Answer 1: Although rheumatoid arthritis can often be clinically indistinguishable from parvovirus B19 infection, the history of prior cold-like illness and concurrent acral rash make parvovirus B19 infection the more likely.
Answer 2: The acuity and widespread distribution of the pain is atypical for osteoarthritis. The lack of abnormalities noted on hand radiographs makes osteoarthritis a less likely cause.
Answer 4: Coxsackievirus causes hand, foot, and mouth disease; however, it is not associated with development of arthritis.
Answer 5: Reactive arthritis (Reiter's syndrome) is a reactive arthritis to bacterial infection that commonly manifests with a triad of arthritis, conjunctivitis, and urethritis.
Servey JT, Reamy BV, Hodge J. Clinical presentations of parvovirus B19 infection. Am Fam Physician. 2007 Feb 1;75(3):373-6.
PMID:17304869 (Link to Abstract)
Franssila R, Hedman K. Infection and musculoskeletal conditions: Viral causes of arthritis. Best Pract Res Clin Rheumatol. 2006 Dec;20(6):1139-57.
PMID:17127201 (Link to Abstract)