Online Letters to the Editor
Case Report:
Exposure to
Parvovirus B19 Presenting as Acute Arthralgia
TO THE EDITOR: A 68-year-old white woman presented to her family physician's office with a four-day history of diffuse bilateral pain and swelling in her wrists, hands, and lower extremities, and a temperature of 101·F (38.3·C). The patient did not have chest pain, palpitations, shortness of breath, a history of injury, or a rash. She was started on 500 mg of naproxen twice daily and was asked to follow up when her laboratory data became available. Laboratory analysis revealed a normal complete blood count, a slightly elevated erythrocyte sedimentation rate of 26 mm per hour, a C-reactive protein level of 23.0 mg per L (219.1 nmol per L), negative rheumatoid factor, and positive antinuclear antibodies (ANA) with a titer of 1:160 in a nucleolar pattern.
The patient returned five days later with a decrease in pain and swelling. Although naproxen had helped alleviate some discomfort, she had developed diarrhea and discontinued its use. At this visit, the patient reported that she had been in close contact with her grandson, whose school recently had experienced an outbreak of parvovirus B19. Subsequent testing for parvovirus B19 antibodies 12 days after the initial presentation revealed an IgG titer of 5.6 and an IgM titer of 8.1. The reference range for both IgM and IgG titer is less than 0.9, negative titer; 0.9 to 1.1, equivocal titer; and greater than 1.1, positive titer. A positive IgG and IgM titer indicates an infection within the last 7 to 120 days. This patient's titers are consistent with her clinical presentation representing an acute infection. The patient was restarted on naproxen, and a decrease in swelling and pain was noted one week later.
Parvovirus B19 infection can have a variety of clinical presentations but is most frequently an asymptomatic infection. Erythema infectiosum, also called fifth disease, causes a classic "slapped cheek" appearance. It is a parvovirus B19 infection most commonly found in children; infected patients present with a low-grade fever, malaise, and a rash. Parvovirus B19 is also known to cause an erythrocyte aplasia, transient aplastic crisis, and in the unborn, hydrops fetalis.1 Arthralgia and arthritis can be symptoms of parvovirus B19, most commonly as acute onset symmetric polyarticular arthritis in the hands. Joint pain and arthritis occur more frequently in infected adult women than in children and adult men. These symptoms often can remain for more than two months. Common laboratory abnormalities include a positive ANA or rheumatoid factor. Forty to 60 percent of adults have antibodies to parvovirus B19.2 There is a steep increase in children older than five years with IgG antibodies, probably indicating that infection is associated with beginning school.3 Treatment of arthropathy from parvovirus B19 is primarily symptom management with nonsteroidal anti-inflammatory drugs.
The differential diagnosis for polyarticular joint pain encompasses many diverse conditions.4 This case of acute arthropathy resulting from parvovirus B19 infection serves as a reminder to consider exposure to parvovirus B19 when a patient presents with an acute transient arthropathy.
REFERENCES
1. Sabella C, Goldfarb J. Parvovirus B19 infections. Am Fam Physician 1999;60:1455-60.
2. Moore TL. Parvovirus-associated arthritis. Curr Opin Rheumatol 2000;12:289-94.
3. Gillespie SM, Cartter ML, Asch S, Rokos JB, Gary GW, Tsou CJ, et al. Occupational risk of human parvovirus B19 infection for school and day-care personnel during an outbreak of erythema infectiosum. JAMA 1990;263:2061-5.
4. Mies Richie A, Francis ML. Diagnostic approach to polyarticular joint pain. Am Fam Physician 2003;68:1151-60.
Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@aafp.org.
Health Problems Associated with Exposure to Pesticides
to the editor: I appreciated the informative editorial, "Health Effects from Pesticide Exposure,"1 by Dr. Calvert.
Recent research links chronic low-level pesticide exposure to many health problems. Pesticide exposure was linked to significantly higher wheezing rates in a study in the United States of 20,468 farmers.2 Long-term agricultural pesticide exposure also has been linked to slower peripheral nerve velocities3 and significantly poorer memory, concentration, motor speed, and color vision.4 Other recent studies have linked chronic low-level pesticide exposure with higher rates of Alzheimer's and Parkinson's disease5 and higher rates of impotence.6
I hope that American Family Physician will continue to provide updated articles on health effects of pesticides and other environmental hazards.
REFERENCES
1.Calvert GM. Health effects from pesticide exposure. Am Fam Physician 2004;69:1613-4,1616.
2.Hoppin JA, Umbach DM, London SJ, Alavanja MC, Sandler DP. Chemical predictors of wheeze among farmer pesticide applicators in the Agricultural Health Study. Am J Respir Crit Care Med 2002;165:683-9.
3.Peiris-John RJ, Ruberu DK, Wickremasinghe AR, Smit LA, van der Hoek W. Effects of occupational exposure to organophosphate pesticides on nerve and neuromuscular function. J Occup Environ Med 2002;44:352-7.
4.Baldi I, Filleul L, Mohammed-Brahim B, Fabrigoule C, Dartigues JF, Schwall S, et al. Neuropsychologic effects of long-term exposure to pesticides: results from the French Phytoner study. Environ Health Perspect 2001;109:839-44.
5.Baldi I, Lebailly P, Mohammed-Brahim B, Letenneur L, Dartigues JF, Brochard P. Neurodegenerative diseases and exposure to pesticides in the elderly. Am J Epidemiol 2003;157:409-14.
6.Oliva A, Giami A, Multigner L. Environmental agents and erectile dysfunction: a study in a consulting population. J Androl 2002;23:546-50.
In reply: Dr. Curtis raises important concerns about chronic health effects that may be related to pesticide exposure. We agree that the evidence supporting these associations continues to build. However, much of this evidence is based on epidemiologic studies. All epidemiologic studies have limitations, and no one study is sufficient to support a causal link between pesticide exposure and chronic illness. This includes the findings from the Agricultural Health Study,1 which is a large prospective cohort study consisting of approximately 90,000 subjects who are pesticide applicators or spouses of pesticide applicators. This study will be an important source of information on health outcomes associated with pesticide exposure. Recent findings from this study,1 which is scheduled to continue through the year 2020, are available online at: http://www.aghealth.org/publications.html. The uncertainty regarding pesticide toxicity does not mean we can ignore the information we have. As was stated in my editorial,2 the reduction of pesticide exposure should be encouraged, including adoption of integrated pest management practices,3 compliance with all pesticide label instructions, and, when necessary, revision of public policies and regulations.
REFERENCES
1. Alavanja MC, Sandler DP, McMaster SB, Zahm SH, McDonnell CJ, Lynch CF, et al. The Agricultural Health Study. Environ Health Perspect 1996;104:362-9.
2. Calvert GM. Health effects from pesticide exposure. Am Fam Physician 2004;69:1613-4,1616.
3. U.S. Environmental Protection Agency. Pesticides and food: what "integrated pest management means." Accessed online March 21, 2005, at: http://www.epa.gov/pesticides/food/ipm.htm.
Maneuver to Deliver Newborns with Shoulder Dystocia
to the editor: The article1 on shoulder dystocia by Drs. Baxley and Gobbo in American Family Physician did not mention a very useful maneuver for reduction of the impacted shoulder.
In my own practice, I have found that as soon as shoulder dystocia is suspected it is highly effective to attempt delivery of the posterior shoulder while other personnel are simultaneously assisting the mother in the McRoberts maneuver. Once the physician determines that the anterior shoulder will not easily deliver, the physician can then gently elevate the head and neck, which pulls the posterior shoulder down further into the pelvis. Sometimes the posterior shoulder will then deliver first, sliding over the perineum. Then the physician can immediately lower the fetal head toward the floor, unlocking the anterior shoulder. Since I have adopted this maneuver I have rarely had to proceed to more invasive maneuvers to reduce the shoulders. The maneuver is simple and can be performed at the same time as the McRoberts maneuver, thus requiring no additional time.
REFERENCES
1. Baxley EG, Gobbo RW. Shoulder dystocia. Am Fam Physician 2004;69:1707-14.
editor's note: This letter was sent to the authors of "Shoulder Dystocia," who declined to reply.
Case Report:
A Movement Disorder Related to Use of Oxycodone
TO THE EDITOR: Oxycodone hydrochloride is a Schedule II opioid analgesic that commonly is used for the treatment of acute and chronic pain syndromes. This case report describes a patient who presented with an apparent sentinel side effect related to this medication.
A 40-year-old black woman reported that she mistakenly took one 5-mg tablet of oxycodone. The medication was her husband's and had been placed in an unlabeled bottle. Approximately 15 minutes after taking the medication, she developed sneezing, facial grimacing, and writhing movements of the upper extremities. Her medical history was negative for psychiatric or neurologic disorders. However, the patient reported a similar episode one year previously when she took the same medication; her symptoms resolved spontaneously over 12 hours.
On physical examination, the patient was alert and oriented; vital signs were within normal limits. She exhibited severe choreoathetoid movements as mentioned. There was no evidence of airway obstruction or anaphylactic reaction.
At the time of presentation, the patient was treated with 25 mg of diphenhydramine, and the local poison control center and a neurologist were consulted. The patient showed little improvement over the first 20 minutes after treatment, and the decision was made to treat the patient with 5 mg of intravenous diazepam. After 10 minutes, the patient's symptoms markedly improved. After observation, she was discharged in improved condition with a prescription for oral diazepam.
A follow-up telephone consultation the next morning revealed complete resolution of her symptoms. The patient was asked to bring the oxycodone to her physician's office for positive identification by a pharmacist.
This case report demonstrates a clear relationship between oxycodone and the development of a transient choreoathetoid movement disorder. A literature search revealed no case reports referencing oxycodone and the development of this movement disorder. The literature does reference similar adverse effects with the use of methadone and meperidine.1 The literature suggests an array of medications useful in the treatment of this patient's symptoms: valproic acid, phenobarbital, pimozide, diazepam, chlorpromazine, and carbamazepine.2 In addition, corticosteroids have been shown to shorten the course of other choreiform disorders.3 In this case, diazepam had clear beneficial effects on this distressing movement disorder.
With the increasing use of opioids for management of pain syndromes, physicians must be vigilant in their assessment of side effects.
REFERENCES
1. Clark JD, Elliott J. A case of a methadone-induced movement disorder. Clin J Pain 2001;17:375-7.
2. Jankovic J. Hyperkinetic movement disorders. In: Rose BD, ed. UpToDate. Wellesley, Mass.: UpToDate, 2005.
3. Thompson JA, Tani LY, Bale JF Jr. Sydenham chorea: the Utah experience (abstract). Abstracts of the 28th annual meeting of the Child Neurology Society. October 13-16, 1999. Nashville, Tenn. Ann Neurol 1999; 46:523.
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