eMedicine Specialties > Dermatology > Viral Infections
Erythema Infectiosum (Fifth Disease)
Updated: Dec 8, 2009
Introduction
Background
Erythema infectiosum (fifth disease) is a common childhood exanthem caused by human parvovirus B19 (PV-B19), an erythrovirus, in which a classic 3-phased cutaneous eruption follows a rarely noticed prodrome.1
Pathophysiology
The development of erythema infectiosum (fifth disease) in children is a normal response to infection by PV-B19. Acute infection in a host who is immunocompetent leads to a Th-1–mediated cellular immune response, with the production of specific immunoglobulin M (IgM) antibodies and subsequent formation of immune complexes. Clinical signs and symptoms of erythema infectiosum (fifth disease) probably result from the deposition of the immune complexes in the skin and joints of individuals with this condition and not from the circulating virus.
Frequency
International
Worldwide, epidemics of erythema infectiosum (fifth disease) tend to occur in the late winter or early spring, with cyclical peaks of incidence occurring every 4-7 years. Approximately 60% of adults are seropositive for PV-B19 by age 20 years. Infection rates vary from 20-50% in schools and households during outbreaks.2,3
Mortality/Morbidity
Erythema infectiosum (fifth disease) is a self-limited illness that resolves without complications or sequelae in its classic childhood form. Infection in adults, hosts who are immunocompromised, and patients who are anemic or pregnant can result in more significant morbidity.
Sex
Males and females are infected equally by erythema infectiosum (fifth disease). Arthropathy is more common in women. Women may be affected by complications from erythema infectiosum (fifth disease) during pregnancy.4,5
Age
Erythema infectiosum (fifth disease) primarily is a disease of children aged 3-15 years, but it can occur at any age.6 PV-B19 infection can lead to the classic symptoms of erythema infectiosum (fifth disease) in adults but more often manifests as an acute arthropathy without cutaneous eruption.
Clinical
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.
Physical
- Pertinent physical findings of erythema infectiosum (fifth disease) predominantly are limited to the skin7 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.
- 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 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.8
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.9
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References
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Further Reading
Keywords
erythema infectiosum, fifth disease, slapped-cheek disease, academy rash, Sticker's disease, Sticker disease, childhood exanthem, Parvovirus B19, PV-B19, PV-B19 infection, Parvoviridae family, acute arthropathy, acute polyarthropathy, coryza, pharyngitis, arthralgias, malar rash
