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Parvovirus B19 is common, with 50–75% of UK adults having evidence of previous infection. Complications, such as arthritis, occur in a small minority. We report a case of parvovirus associated arthritis causing diagnostic confusion in a patient known to have Behçet's disease.
A 34 year old white woman presented with a small joint polyarthritis, low back discomfort, severe heel pain, and patchy sensory disturbance, after a febrile illness with a rash. She had had Behçet's disease since the age of 3 years, manifest by arthralgia, mouth, nasal and genital ulcers, conjunctivitis, facial swelling, and livedo reticularis. Before her presentation, her Behçet's disease had been relatively well controlled by 100 mg of azathioprine a day, the only residual symptoms being pain and morning stiffness of 45 minutes affecting her fingers, wrists, elbows, and shoulders, and livedo reticularis.
On presentation she was afebrile, with cervical lymphadenopathy. The liver and spleen tip were palpable. She had mild metacarpophalangeal and wrist synovitis, bilateral knee effusions, and was exquisitely tender bilaterally over the plantar fascia. Her sacroiliac joints were tender. There was subjective symmetrical sensory loss to pin prick and light touch on the dorsum of the feet and the lateral aspect of the hands. Neurological examination was otherwise unremarkable. An x ray examination of the hands, calcaneum, and sacroiliac joints was normal, as was the full blood count, and C reactive protein. Rheumatoid factor, antinuclear antibodies, antineutrophil cytoplasmic antibodies, and anticardiolipin antibodies were not detected. She was treated initially with ibuprofen and colchicine, without improvement. The addition of methylprednisolone acetate 120 mg intramuscularly and local steroid injections to the plantar fascia (12.5 mg hydrocortisone acetate) brought about rapid improvement. All her symptoms resolved over the following few weeks. Parvovirus B19 IgM was subsequently found to be strongly positive by both enzyme linked immunosorbent assay (ELISA) and radioimmunoassay, indicative of recent infection.
Sacroiliitis is an unusual feature of Behçet's disease,1 2 and plantar fasciitis has not been previously described in this disorder. Parvovirus arthritis is an uncommon sequela of a common viral exanthem. The usual presentation is of an acute onset polyarthritis, resembling rheumatoid disease, which may follow a flu-like illness and rash.3 4 Transient neurological disease may occur.5 Parvovirus associated relapse of spondylitis after a symptom-free period of 15 years has been described.6
The diagnosis in our case was complicated by superficial similarities to the arthritis of Behçet's disease. The possibility of neurological involvement was a new, and worrying, feature. However, there were no additional features of active Behçet's disease, such as mouth or genital ulcers, which had been associated with previous exacerbations. The unusual features of seronegative arthritis and prior febrile illness raised the possibility of a coincidental reactive arthritis. Despite the presence of some atypical features, we consider parvovirus B19 to be the most likely cause of this patient's illness, on both clinical and serological grounds.
This case illustrates the importance of considering the diagnosis of coincidental parvovirus in patients with pre-existing rheumatic diseases where there are unusual features. Because parvovirus associated arthritis is usually self limiting, this diagnosis may allow a more conservative approach to treatment.
We thank Professor AJ Pinching for allowing us to report on his patient.
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