A 55 year old man is evaluated for a 6 week history of severe fatigue, prolonged morning stiffness of the hands and feet, and arthralgia. She has a history of hypothyroidism controlled with L-thyroxine. She uses ibuprofen, which has not helped to relieve her pain. Her mother had osteoarthritis of the knees.
On physical exam, her temp is 37.1 degrees C (98.7 F), BP is 137/79, HR is 85/min, and RR is 14/min. Her BMI is 31. Heart and lung exam is normal. No rash is apparent. MSK exam reveals tenderness and swelling of the 2nd and 3rd MCP joints bilaterally. Her elbows are stiff but have full ROM and do not have signs of synovitis. There is squeeze tenderness of the bilateral metatarsophalangeal joints.
Labs
CBC wnL, Rheumatoid factor negative, TSH 1.9 mU/L, Anti-cyclic citrullinated peptide antibodies positive, IgG antibodies against parvovirus B19 positive, and IgM antibodies against parvovirus B19 negative.
Which of the following is the most likely diagnosis?
A) HypothyroidismB) Parvovirus B19 Infection
C) Polymyalgia rheumatica
D) Rheumatoid arthritis
E) Systemic lupus erythematosus
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