Prabhjot Chohan, ND, MD (India), CCRA
Abstract
Parvovirus B19 infection in adults can present with polyarthralgia and rash, often resembling post-streptococcal sequelae such as acute rheumatic fever or reactive arthritis. This case describes a 36-year-old female with polyarthralgia and rash occurring six weeks after completing antibiotics for Group A streptococcal pharyngitis. Initial investigations ruled out autoimmune and bacterial causes; subsequent serology confirmed acute Parvovirus B19 infection. The patient was treated with a naturopathic anti-inflammatory regimen including Boswellia serrata, Curcuma longa, Quercetin, Bromelain, Omega-3 fatty acids, and vitamin D3, resulting in significant symptom resolution. This case highlights the importance of early serological testing to distinguish viral from bacterial arthritis, preventing misdiagnosis and guiding appropriate management.
Introduction
Human Parvovirus is a small, single-stranded DNA virus associated with varied clinical presentations. The prominent clinical syndromes associated with Parvovirus include the Fifth disease/Erythema infectiosum in children; arthropathy/arthralgia mainly in adults; transient aplastic crisis in those with chronic hemolytic disorders; fetal infection leading to non-immune hydrops fetalis, intrauterine fetal death, miscarriage, or cardiomyopathy; and pure red blood cell aplasia in immunocompromised individuals.1 Polyarthralgia and arthritis associated with Parvovirus are more common in adults (50-80%) than in children (8%).2 Adults typically present with rheumatoid arthritis like a symmetrical small joint pattern involving the wrists, metacarpophalangeal, and proximal interphalangeal joints 2,3, while children have an asymmetric large-joint oligoarthritis, usually involving the knee.2 Arthritis symptoms usually begin within 5-10 days of prodromal illness, can last a few days to months on rare occasions, and are managed by NSAIDs.2 An uncommon presentation of polyarthralgia is remitting seronegative symmetrical synovitis with pitting edema (RS3PE), which is associated with acute symmetrical synovitis of the wrists, carpal joints, and phalanges, with pain, swelling, and pitting edema of the dorsal surface of either the hands or feet or both, resembling a boxing glove hand. This is accompanied by an erythematous-papular purpuric eruption on the trunk and extremities.4
On the other hand, acute rheumatic fever occurs mainly in children aged 5-14 years within 2-4 weeks of Group A streptococcal infection, and symptoms resolve within 1-3 weeks.5 According to the Jones Criteria 2015 for diagnosing acute rheumatic fever, the major criteria are carditis, arthritis, chorea, erythema marginatum, and subcutaneous nodules. The minor criteria include polyarthralgia, fever (≥38.5°C), ESR ≥60 mm per hour, CRP ≥3.0 mg/dL, and a prolonged PR interval. The diagnosis of initial ARF requires two major manifestations or one major plus two minor criteria in all patient populations with evidence of prior Group A Streptococcal infection. Arthritis is effectively treated with anti-inflammatory medications such as aspirin and NSAIDs.6
In comparison, post-streptococcal reactive arthritis occurs more acutely within 10 days of exposure to Streptococcal infection. It has a bimodal age distribution, with peaks at ages 8-14 years and 21-37 years, and arthritis symptoms can persist for two months.7 It is diagnosed in patients with polyarthritis with recent exposure to Streptococcal infection and no major Jones criteria. Joint involvement is additive and persistent, affecting small and large axial joints. It may present in monoarticular, oligoarticular, or polyarticular patterns and demonstrates a moderate response to NSAIDs.8
Case presentation
A 36-year-old female patient presented to the clinic for a follow-up from the Emergency room. The patient was seen in the ER a day prior for polyarthralgia that started four days earlier. She initiated Ibuprofen 200mg, two tabs for two days per the ER recommendation. Additional laboratory testing was recommended to confirm the diagnosis for her symptoms. Joint pain was 5/10 in intensity, continuous, in bilateral knees and hands, progressing to feet, shoulders, elbows, and neck. She had pain in her chest on deep inhalation. These symptoms were preceded by a rash on the back and chest that developed a week before the joint pain. Her past medical history was notable for three courses of antibiotics in the last 3 months for Strep throat, the last course finished about 6 weeks before the onset of her symptoms. Her vitals were within normal limits except that she was slightly bradycardic (BP=110/60mmHg, PR=56bpm, RR=19/min, pO2=99%, T=97.3°F/36.56°C). On physical examination, moderate swelling with tenderness was noted in the bilateral hands, feet, and knees, accompanied by pain on active movement at these joints. Examination of the abdomen, cardiovascular system, and respiratory system was unremarkable.
The differential diagnosis considered included infectious causes such as viral arthritis and Lyme arthritis; postinfectious reactive arthritis, including acute rheumatic fever and post-streptococcal reactive arthritis; autoimmune causes, such as rheumatoid arthritis and systemic rheumatic illnesses; degenerative causes, such as osteoarthritis; and nutritional causes, such as Vitamin D deficiency. Investigations from the ER showed that CBC, CMP, ESR, PT/PTT, and Uric acid were within normal limits, except for Hematocrit (34.5, low, normal 36-44) and Absolute Lymphocyte count (0.73, low, normal 1000-4000). Laboratory panels were ordered to rule out various causes of arthritis. The patient was started on Omega-3 fatty acids 1000mg, one capsule once a day, and recommended to continue taking Ibuprofen as needed for pain. Given her preference for natural therapies, she was also recommended a joint support supplement containing Boswellia serrata, Curcuma longa, Quercetin, and Bromelain to be taken at a dosage of three capsules twice a day.
Visit 2
The patient reported an 80% improvement in joint pain at a follow-up visit one week after treatment. She had erythema on her face that persisted for two days and on her arms that started on the day of the visit. She continued to have chest pain on deep inhalations. Vitals were within normal limits (BP=106/62mmHg, PR=64bpm, RR=18/min, pO2=99%, T=97.8°F (36.5°C). The physical examination was positive for bilateral erythema of the face. No swelling or tenderness was noted on the hands, knees, and feet, with no restriction of the movement of joints. Examination of the abdomen, cardiovascular system, and respiratory system was normal.
Laboratory tests showed that the patient was negative for Lyme disease antibodies, Rheumatoid factor, anti-CCP antibodies, and ANA, ruling out Lyme disease, Rheumatoid arthritis, and systemic rheumatic illnesses, respectively. Notably, her Vitamin D level was at 26.9 (low, 30-100ng/ml). Given her ongoing chest pain with deep inhalation, an EKG was performed. The EKG revealed a slow sinus rhythm, but otherwise within normal limits. The patient was started on Vitamin D3 5000 IU, one capsule once daily, with follow-up testing in 3-4 months to assess the levels. She was advised to continue with Omega3 and the joint support supplement that were recommended on the last visit.
Visit 3
The clinic received notification about the outbreak of Parvovirus at the patient’s workplace a day after Visit 2. The patient was promptly contacted, and it was recommended that a blood test be done for Parvovirus serology. She tested positive for Parvovirus, with both B19 IgG and IgM present. She was advised to continue the same treatment and incorporate supportive care measures, such as increased fluid intake due to enhanced metabolism, steam inhalation, and saltwater gargles for airway hygiene. Infection control strategies, such as handwashing and masking, were also discussed to prevent further transmission of the virus. She was recommended to take a natural supplement for immune support; however, she preferred to continue with the supplement prescribed for joint support.
Phone follow-up
No additional in-person follow-up visits were conducted. At a 4-month phone consultation, the patient reported that the rash and swelling subsided after the office visits. However, her fatigue persisted for 2 months post-infection. She was compliant with taking Vitamin D3, Omega-3, and the supplement for joint support.
Discussion
The patient tested positive for parvovirus infection. She worked as a teaching assistant at a preschool and had documented exposure to an outbreak of parvovirus among young children. Her acute presentation, followed by a rapid resolution of symptoms, supports the diagnosis of viral arthritis. Viral arthritis is a form of polyarthritis that causes inflammation of the joints and synovial tissue, also known as synovial arthritis. The episode lasts less than four weeks, and there is a history of exposure to a virus, which may include recent travel, sick contacts, fever, and/or rash.2 Her serological testing confirmed the diagnosis of parvovirus, and laboratory investigations showed a mild decrease in hematocrit and lymphocytes. These findings align with current evidence suggesting a mild decline in hematological parameters such as hemoglobin, hematocrit, mean corpuscular volume, mean cellular hemoglobin, and mean hemoglobin concentration associated with parvovirus infection,9 along with a reduction in the total number of lymphocytes in viral infections.10
The onset of the patient’s symptoms occurred approximately six weeks after completing a third course of antibiotics for acute streptococcal pharyngitis. This timeline does not fall within the typical ARF and post-streptococcal reactive arthritis window period.6,8 Studies have shown that the treatment with antibiotics further decreases the possibility of progression to ARF, which has led to its decreased incidence in developed countries.5 Although the case appeared to be a sequela of the Streptococcal infection, anti-streptolysin titers were not performed in this case, as the presentation and resolution of symptoms were acute. It is worth noting that the extent of streptolysin response can be altered by antibiotics, age, season, and number of episodes of Streptococcal infection.11
Parvovirus arthritis responds to the anti-inflammatory action of NSAIDs.2 The natural supplement containing Boswellia, Curcumin, Quercetin, and Bromelain targets the inflammatory pathways. Boswellia has antioxidant properties due to its abundant content of terpenoids and other bioactive phytochemicals, which have a therapeutic effect on arthritis.12 Curcumin, Quercetin, and Bromelain act on proinflammatory markers, including chemokines, interleukins, tissue necrosis factor, and prostaglandins, to decrease the joint inflammation.13,14,15 Omega-3 has anti-inflammatory action with EPA and DHA diminishing the release of cytokines and reducing the activity of immune cells.16 Vitamin D3 also plays a key role in modulating the immune response by regulating the genes involved in inflammation in the body.17 Thus, integration of conventional medicine and naturopathic modalities facilitated the resolution of the patient’s symptoms.
Conclusion
This case illustrates the difference between the presentation and management of Parvovirus arthritis and the sequelae of streptococcal infection, manifesting as acute rheumatic fever and post-streptococcal arthritis. Parvovirus arthritis is typically an acute condition with rapid resolution of symptoms, as is common with viral arthritis; however, a small percentage of cases can become chronic. Serology testing for confirming potential diagnoses should be conducted as early as possible. Additionally, testing for basic nutritional deficiencies must be included as part of the arthritis work-up. This not only establishes a correct clinical diagnosis but also facilitates the formulation of a timely management plan.
Abbreviations
IgM-Immunoglobulin M, IgG-Immunoglobulin G, ESR-Erythrocyte Sedimentation Rate, CRP-c-Reactive Protein, ARF-Acute Rheumatic Fever, NSAIDS-Non-Steroidal Anti-Inflammatory drugs, ER-Emergency Room, BP-Blood Pressure, PR-Pulse Rate, RR- Respiratory Rate, SpO2-Oxygen saturation, T-Temperature, F-Fahrenheit, C-Celsius, CBC-Complete Blood Count, CMP-Complete Metabolic Profile, ESR-Erythrocyte Sedimentation Rate, PT-Prothrombin time, PTT-Partial Thromboplastin Time, anti-CCP-Anti-cyclic citrullinated proteins, ANA-Antinuclear antibody, EKG-Electrocardiogram, EPA-Eicosapentaenoic acid, DHA-Docosahexaenoic acid
Consent
The patient gave her written informed consent for the publication of this case report.
Acknowledgments
I thank Dr. Sarah Acosta Smith for her guidance in patient care and Dr. Brendan Smith for his guidance and contribution to the research aspect and writing this case report.
Prabhjot Kaur Chohan is a naturopathic medical doctor, medical writer, and clinical researcher. She completed her doctorate in naturopathic medicine (ND) from the Canadian College of Naturopathic Medicine, Toronto in 2022. She also has a doctorate in medicine (MD) from India and cherishes the blend of naturopathic and conventional medicine. Dr. Chohan gained superb experience in integrative primary care through her advanced family medicine residency at the Family Health Centers in Okanogan, Washington, and her general medicine residency at Sonoran University, Arizona. Her interests include autoimmune conditions, infectious diseases, women’s health, and mental health.
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