Erythema Infectiosum (Fifth Disease) Clinical Presentation

  • Author: Glenn L Zellman, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Jan 26, 2012
 

History

  • Erythema infectiosum (fifth disease) typically has an incubation period of 4-14 days and is spread primarily via aerosolized respiratory droplets.
  • Transmission also occurs through blood products and from mother to fetus.
  • The prodromal phase of erythema infectiosum (fifth disease) often is mild enough to be noticed only rarely but may include headache, coryza, low-grade fever, pharyngitis, and malaise.
  • Infrequently, nausea, diarrhea, arthralgias, and abdominal pain may occur.
  • In hosts who are immunocompetent, the patient is viremic and capable of spreading the infection only during the incubation period.
  • Classic cutaneous findings follow within 3-7 days for some patients, while other patients may manifest no findings.
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Physical

  • Pertinent physical findings of erythema infectiosum (fifth disease) predominantly are limited to the skin[8] and joints.
    • Skin (first stage): The exanthem begins with the classic slapped-cheek appearance. The bright red erythema appears abruptly over the cheeks and is marked by nasal, perioral, and periorbital sparing, as demonstrated in the image below. The exanthem may appear like a sunburn, occasionally is edematous, and typically fades over 2-4 days. Classic slapped-cheek appearance of fifth disease.Classic slapped-cheek appearance of fifth disease.
    • Skin (second stage): Within 1-4 days of the malar rash, an erythematous macular-to-morbilliform eruption occurs primarily on the extremities. While the eruption tends to favor the extensor surfaces, it can involve the palms and soles. Pruritus is rare.
    • Skin (third stage): After several days, most of the second stage eruption fades into a lacy pattern, with particular emphasis on the proximal extremities, as demonstrated in the image below. Despite its synonym, slapped-cheek disease, the reticulate pattern is distinctly characteristic for erythema infectiosum and may be the only manifestation of the illness. The third stage lasts from 3 days to 3 weeks. After starting to fade, the exanthem may recur over several weeks following physical stimuli, such as exercise, sun exposure, friction, bathing in hot water, or stress. Pathognomonic reticulated lacy-appearing eruption Pathognomonic reticulated lacy-appearing eruption of fifth disease.
    • Joints: When adults are exposed to PV-B19, an acute polyarthropathy is more likely to result than classic erythema infectiosum. Polyarthropathy may start with a typical prodromal illness and some cutaneous aspect of erythema infectiosum but more often manifests simply by a new onset of symmetric joint pain. Arthropathy is more common in women and can last for days to months. Sites most commonly affected include joints of the hands, wrists, knees, and ankles. Unlike rheumatoid arthritis, joint pain worsens over the day, and no joint destruction occurs. The synovial fluid is acellular and devoid of viral particles. An association with DR4 histocompatability alleles is recognized.
    • Other: Rarely, patients may have some mild constitutional symptoms and/or adenopathy. Takeda et al reported renal involvement.[9]
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Causes

Erythema infectiosum (fifth disease) is caused by infection with PV-B19, a member of the Parvoviridae family. PV-B19 is the virus with the smallest DNA known to cause illness in humans, and it consists of a single-stranded DNA core surrounded by an unenveloped icosahedral capsid. PV-B19 requires mitotically active cells and a globoside cellular receptor for propagation, thus making erythroid cell lines a prime target. The tropism for human erythroid progenitor cells and other rare sites of the globoside receptor (eg, endothelial cells, placental cells) is responsible for the more serious complications associated with the viral infection.[10]

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Contributor Information and Disclosures
Author

Glenn L Zellman, MD  Consulting Staff, Department of Internal Medicine, University Hospital, Tamarac, Florida

Disclosure: Nothing to disclose.

Specialty Editor Board

Bernice R Krafchik, MBChB, FRCPC  Professor Emeritus, Department of Pediatrics, Section of Dermatology, University of Toronto

Bernice R Krafchik, MBChB, FRCPC is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, Canadian Medical Association, College of Physicians and Surgeons of Ontario, Royal College of Physicians and Surgeons of Canada, and Society for Pediatric Dermatology

Disclosure: Nothing to disclose.

Richard P Vinson, MD  Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association

Disclosure: Nothing to disclose.

Van Perry, MD  Assistant Professor, Department of Medicine, Division of Dermatology, University of Texas School of Medicine at San Antonio

Van Perry, MD is a member of the following medical societies: American Academy of Dermatology and American Society for Laser Medicine and Surgery

Disclosure: Nothing to disclose.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

References

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Classic slapped-cheek appearance of fifth disease.
Pathognomonic reticulated lacy-appearing eruption of fifth disease.
 
 
 
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