USMLE® Step 1 style questions USMLE
A 30-year-old woman comes to the office because of joint pain and stiffness. The patient reports bilateral pain of her hand, wrist and knee joints for the past 10 days. The symptoms are worse in the morning and get better with movement. The patient has had no associated chills, fever or rash. Past medical history is significant for hereditary spherocytosis. Family history is significant for gout in the patient’s father. The patient is a school teacher and does not use tobacco, alcohol or illicit drugs. Vitals are within normal limits. Physical examination shows mild swelling with no redness, warmth or tenderness of the affected joints. Oropharyngeal examination is unremarkable. X-ray of both hands is normal. Considering the most likely cause of this patient’s condition, she is at increased risk of developing which of the following complications?
Content Reviewers:Rishi Desai, MD, MPH
Parvovirus B19 is the smallest known DNA animal virus, coming in at an itty bitty 18 to 28 nanometers in diameter.
In comparison, the average size of a single human red blood cell is a whopping 7200 nanometers!
While it’s mostly known for causing fifth disease, or “slapped cheek syndrome,” in children, parvovirus B19 can also affect adults and it can cause serious illness in individuals with pre-existing conditions like sickle-cell anemia and HIV.
Parvovirus B19 is part of the parvoviridae family.
It’s a single-stranded DNA virus surrounded by an icosahedral capsid, which is a spherical protein shell made up of 20 equilateral triangular faces.
And it’s “naked” because the capsid isn’t covered by a lipid membrane.
Parvovirus B19 is primarily transmitted by respiratory droplets when someone coughs or sneezes.
You can also catch it via an infected blood transfusion and a pregnant female can also transmit it through the placenta to her unborn child.
Now, although the virus first enters cells of the respiratory tract by binding to receptors on host cells, it doesn’t replicate in them.
Instead it keeps travelling through cells and into the circulatory system until it reaches bone marrow, where red blood cells are made, a process called erythropoiesis.
Once there, parvovirus B19 uses receptor-mediated endocytosis to enter erythroid progenitor cells, also called proerythroblasts, the early cells that eventually become red blood cells.
It then uses these cells’ DNA replication machinery in the nucleus to replicate its DNA and assemble new copies of the virus.
Why not simply replicate in cells of the respiratory system?
Well it turns out that Parvovirus B19 needs two things: it prefers to bind to a specific receptor, the P antigen, which is found in large numbers on proerythroblasts’ cell membrane and it needs cells that pass through the S phase of the cell cycle, which is the phase where cell DNA is replicated.
As the virus replicates and matures, it produces a protein called non-structural protein 1 or NS1, which is toxic to human cells and causes apoptosis, or cell death.
This means that erythropoiesis breaks down, and fewer new red blood cells go into circulation as a result of parvovirus B19 infection.
But thankfully this is only temporary.
When the cell dies, it bursts open, releasing copies of the virus into the blood, also called viremia.
For individuals with a functioning immune system, this typically happens between 10 and 14 days after first becoming infected with the virus.
Parvovirus B19 is most common in young children and those who live or work with them, like parents, siblings, and daycare workers.
Fetuses are at risk of parvovirus B19 if their pregnant mother has never had the virus in the past.
The incubation period for parvovirus B19 - basically the period before viremia starts - is between 4 and 14 days, after which symptoms develop.
Flu-like symptoms - like a mild fever, headache, and aching muscles - are most common during viremia.
Once the immune response begins and the viremia ends, these symptoms go away and some individuals will then develop a rash and/or joint pain.
A lace-like rash might also appear on the trunk and the limbs.
Joint pain and inflammation, or arthralgia and arthritis, linked to parvovirus B19 infection usually affects the small joints of the hands, wrists, feet, and knees, and are often symmetrical, meaning that the same joints on both sides of the body will be affected.
Children tend to get the rash whereas adults are more likely to develop joint pain, but it’s not exclusive to either group.
There are a few complications caused by parvovirus B19 infection.
Parvovirus B19 is a single-strand DNA virus of the parvoviridae family, which is commonly known for causing diseases in the pediatric population, though it can also affect adults.
Parvovirus B19 is primarily spread by infected respiratory droplets and causes the Fifth disease or "slapped cheek syndrome" in children, characterized by a distinctive red rash on the cheeks. It can also cause redness and joint pain (arthritis) in adults. Parvovirus B19 can also affect the bone marrow, resulting in anemia secondary to decreased erythropoiesis. Anemia can even be worse in patients with pre-existing bone marrow stress, for example, sickle cell anemia or hereditary spherocytosis which can lead to an aplastic crisis.
Treatment for parvovirus B19 varies according to the symptoms, and can involve blood transfusion for transient aplastic crisis and hydrops fetalis and immune globulin intravenous therapy for chronic infections.