Tuesday, April 14, 2009

The differential 'Slaps' you in the face

When one talks about approach to new polyarthritis in the ER the differential diagnosis is quite extensive but should include.......

Infectious:
  • viral (see below)
  • bacterial (disseminated gonococcal, endocarditis...)
  • lyme disease
  • fungal

Inflammatory:

  • SLE, RA, Stills Disease, IBD, psoriatic
  • Sarcoidosis (Lofgrens)
  • serum sickness reaction
  • acute rheumatic fever
Finally....Always important to remember a bit about parvovirus B19 and the various clinical presentations.....



Erythema Infectiosum (5th disease)
  • Incubation 4-28 days
  • Prodrome: low grade fever, h/a, mild URTI
  • Characteristic rash (3 phases): Slapped cheek appearance (facial flushing), Diffuse macular erythema, Central clearing of macular lesions – lacy, reticulated appearance
  • Rash disappears over 1-3 wks but can wax and wane (sun exposure, exercise, heat, stress)

Arthropathy

  • Females > males, adolescents > children
  • likely post-infectious resolves in 2-4 wks
  • range in symptoms from arthralgia with morning stiffness to frank arthritis
  • most common: hands, writsts, knees, ankles

Aplastic crisis

  • Transient arrest of erythropoiesis and absolute reticulocytopenia – sudden fall in hemoglobin in pts with chronic hemolysis (RBC life shorter)
  • Incubation period for transient aplastic crisis is shorter – occurs coincident with viremia

Chronic Anemia:

  • Immunocompromised

Fetal Infection:

  • Nonimmune fetal hydrops and intrauterine fetal demise, risk fetal loss
  • Monitor for signs of fetal anemia / hydrops – U/S with Doppler to measure peak systolic flow velocity in MCA

Myocarditis:

  • Rare cause of lymphocytic myocarditis

Other cutaneous:

  • PPGSS – papular-purpuric gloves and stocking syndrome – fever, pruritis and painful edema extremities

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