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Snapshot
  • A 25-year-old woman presents to the emergency room for painful joints. She has had pain in her bilateral hands and wrists for the past few days. She also had a low-grade fever and mild upper respiratory symptoms. She is 14-weeks pregnant and has had good prenatal care. She works as a kindergarten teacher. On physical exam, the joint in her hands are slightly swollen and tender. A fetal ultrasound shows hydrops fetalis.
Introduction
  • Classification
    • parvovirus B19
      • non-enveloped, linear, single-stranded DNA virus
      • causes a variety of diseases
        • aplastic crisis in patients with red blood cell disorders
        • pure red blood cell aplasia in adults
        • rheumatoid arthritis-like symptom in adults
        • erythema infectiosum (fifth disease) in children
        • hydrops fetalis in fetuses if pregnant women are infected
      • transmission via respiratory droplets
  • Epidemiology
    • incidence
      • highest in winter and spring
    • demographics
      • children > adults
    • risk factors
      • sickle cell disease
      • thalassemia
      • hereditary spherocytosis
      • close proximity to others (e.g., school or daycare centers)
  • Pathogenesis
    • infects red blood cells through the P antigen
    • viral replication in bone marrow causes the death of erythroid progenitor cells
    • causes hydrops fetalis in fetuses due to severe fetal anemia
Presentation
  • Symptoms
    • prodrome with flu-like symptom
    • hydrops fetalis and fetal death in pregnant women
    • polyarthropathy
      • small joints (e.g., hands)
  • Physical exam
    • erythema infectiosum
      • first rash appears as slapped cheeks
      • subsequent rash is an erythematous maculopapular rash on the trunk and limbs, which may appear reticular or lacy
Studies
  • Labs
    • parvovirus-specific immunoglobulin M
    • detection of parvovirus on polymerase chain reaction
    • anemia
  • Making the diagnosis
    • based on clinical presentation
    • may be confirmed with laboratory studies
Differential
  • Measles
    • distinguishing factors
      • confluent maculopapular rash without slapped cheeks rash
      • Koplik spots on buccal mucosa
  • Rubella
    • distinguishing factor
      • non-confluent maculopapular rash that spreads from face to body
Treatment
  • Management approach
    • mainstay of treatment is supportive care
  • Conservative
    • supportive care
      • indication
        • all patients
      • modalities
        • analgesics
        • hydration
  • Medical
    • non-steroidal anti-inflammatory drugs
      • indication
        • polyarthropathy
Complications
  • Myocarditis
  • Behcet syndrome
  • Aplastic crisis
 

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Questions (5)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

(M1.MC.10) A 9-year-old male presents to your office with an indurated rash on his face. You diagnose erythema infectiosum. Which of the following is characteristic of the virus causing this patient's disease? Review Topic

QID: 101469
1

Enveloped virus with double-stranded DNA

17%

(46/265)

2

Enveloped virus with single-stranded DNA

20%

(52/265)

3

Enveloped virus with single-stranded RNA

10%

(26/265)

4

Non-enveloped virus with double-stranded DNA

12%

(31/265)

5

Non-enveloped virus with single-stranded DNA

39%

(103/265)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(M1.MC.201) A 17-month-old male is brought to your office by his mother for evaluation of a rash. Four days ago, the child experienced low-grade fever, irritability, and rhinorrhea. Physical examination is notable for the rash seen in Figure A. To which viral family does the most likely etiologic agent belong? Review Topic

QID: 106228
FIGURES:
1

Hepadnavirus

0%

(0/12)

2

Herpesvirus

25%

(3/12)

3

Parvovirus

58%

(7/12)

4

Togavirus

0%

(0/12)

5

Picornavirus

8%

(1/12)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
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