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Pediatrics, Fifth Disease or Erythema Infectiosum
Updated: Mar 19, 2009
Introduction
Background
Erythema infectiosum is usually a benign childhood condition characterized by a classic slapped-cheek and lacy exanthem. It is an infection caused by human parvovirus (HPV) B19. Human parvovirus B19 also is associated with other hematologic, rheumatologic, and neurologic conditions, including polyarthropathy, aplastic anemia, and hydrops fetalis.
Pathophysiology
Human parvovirus B19, a member of the family Parvoviridae, is a heat-stable, single-stranded DNA virus. Human parvovirus B19 was accidentally discovered in 1975; it is the only parvovirus known to infect humans. Transmission occurs through respiratory secretions, possibly through fomites, and parenterally via vertical transmission from mother to fetus and by transfusion of blood or blood products.
The incubation period is usually 7-10 days but can be 4-21 days. The mechanism producing the dermatologic and rheumatologic features is unknown but thought to represent antigen-antibody (Ag-Ab) complexes in the skin and joints.
Arthropathy is observed most commonly in adult women and occurs in fewer than 10% of children. It is a symmetric polyarthritis, usually involving finger joints. The onset of joint symptoms occurs 2-3 weeks after exposure.
The association of human parvovirus B19 and aplastic anemia is thought to be due to the affinity and cytotoxicity of the virus for erythroid progenitor cells. This complication is primarily observed in patients with underlying hemolytic anemias (eg, sickle cell disease, thalassemia) or immunodeficiency states (eg, leukemia, HIV). These disease states depend on high red-cell production. The hematocrit of these patients may drop as much as 10-15% per day during acute infection.
Most patients have a human parvovirus B19 aplastic crisis only once, and a rash following aplastic crisis is rare. Previously healthy patients also develop transient (and usually clinically insignificant) bone marrow suppression and reticulocytopenia. In rare cases, mild lymphopenia, neutropenia, and thrombocytopenia also may occur.
Fetal transmission may result in severe anemia with resultant congestive heart failure and fetal hydrops. This occurs in fewer than 10% of primary maternal infections. Recent studies report 1-9% risk of fetal death in pregnant women exposed to active human parvovirus infection, with greater risk of fetal loss in early pregnancy. Approximately one half of women of childbearing age are seropositive; therefore, they are immune and are of no risk to the fetus. No evidence suggests specific congenital malformations due to in-utero exposure to human parvovirus B19.
Associations of human parvovirus B19 infection include encephalitis, neuropathies, myocarditis, nephritis, systemic lupus erythematosus (SLE), Henoch-Schönlein purpura (HSP), and rheumatoid arthritis. The exact role of HPV B19, if any, in these diseases is unclear.
Frequency
United States
Sporadic cases occur, but outbreaks are more common. Up to 60% of the population is seropositive for anti-HPV B19 immunoglobulin G (IgG) by age 20 years. The incidence peaks in winter and early spring.1 Human parvovirus B19 epidemics appear to occur in cyclical fashion every 4-7 years and are estimated to affect 30-50% of US households. Community epidemics usually last 3-6 months. Subclinical infections are common.
International
The disease occurs worldwide, especially in temperate climates.
Mortality/Morbidity
Arthropathy is observed in fewer than 10% of children with fifth disease. Incidence of human parvovirus B19-induced aplastic crisis in patients with chronic hemolytic anemia is 2-5% per year.
Sex
Females are affected slightly more often than males.
Age
Approximately 70% of total cases occur in children aged 5-15 years. Infants and adults are affected infrequently.
Clinical
History
Erythema infectiosum is usually a biphasic illness.
- Mild prodromal symptoms begin approximately 1 week after exposure and last 2-3 days.
- Headache (20% of pediatric patients)
- Fever (20%)
- Sore throat (15%)
- Pruritus (15%)
- Coryza (10%)
- Abdominal pain (10%)
- Arthralgias (10%)
- The symptoms above occur more frequently in adults than in children, especially joint symptoms (up to 50%).
- These symptoms precede a symptom-free period of about 7-10 days, followed by a typical exanthem that occurs in 3 phases.
- Phase 1: A bright red, raised, slapped-cheek rash with circumoral pallor develops.2 The nasolabial folds are usually spared.
- Phase 2: This phase occurs 1-4 days later and is characterized by an erythematous maculopapular rash on proximal extremities (usually arms and extensor surfaces) and trunk, which fades into a classic lace-like reticular pattern as confluent areas clear.2 The palms and soles usually are spared.
- Phase 3: Frequent clearing and recurrences for weeks, and occasionally months, may be due to stimuli such as exercise, irritation, or overheating of skin from bathing or sunlight.
- The rash is often pruritic, especially in adults.
- Enanthems are virtually never observed.
- The rash is observed in approximately 75% of human parvovirus B19 – infected pediatric patients but in less than 50% of infected adults.
- The patient is no longer infectious when the rash appears. Patients with aplastic crisis continue to be viremic and infectious until RBC recovery occurs.
Physical
- Look for involved arthritis.
- In decreasing order of frequency, site of involvement are the following:
- Metacarpophalangeal and/or interphalangeal areas
- Knees
- Wrists
- Ankles
Causes
- Human parvovirus B19 is the cause.
- Complications of parvovirus infection are observed in patients with underlying chronic hemolytic anemias, congenital or acquired immunodeficiency states, and pregnancy.
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References
American Academy of Pediatrics. Red Book: 2006 Report on the Committee of Infectious Diseases. 2006:484-487.
Servey JT, Reamy BV, Hodge J. Clinical presentations of parvovirus B19 infection. Am Fam Physician. Feb 1 2007;75(3):373-6. [Medline].
Anderson LJ. Human parvovirus. In: Richman DD, Whitley RJ, Hayden FG, eds. Clinical Virology. New York: Churchill Livingston Inc; 1997:613-31.
Cherry JD. Parvoviruses. In: Feigin RD, Cherry JD, eds. Textbook of Pediatric Infectious Diseases. Philadelphia: WB Saunders Co; 1992:1626-33.
Cohen B. Parvovirus B19: an expanding spectrum of disease. BMJ. Dec 9 1995;311(7019):1549-52. [Medline].
Feder HM Jr, Anderson I. Fifth disease. A brief review of infections in childhood, in adulthood, and pregnancy. Arch Intern Med. Oct 1989;149(10):2176-8. [Medline].
Hall CJ. Parvovirus B19 infection in pregnancy. Arch Dis Child Fetal Neonatal Ed. Jul 1994;71(1):F4-5. [Medline].
Hammond GW. Parvovirus. In: Long SS, Pickering LK, Prober CG, eds. Principles and Practice of Pediatric Infectious Diseases. New York: Churchill Livingston Inc; 1997:1205-9.
Heegaard ED, Hornsleth A. Parvovirus: the expanding spectrum of disease. Acta Paediatr. Feb 1995;84(2):109-17. [Medline].
Jones MF, Wold AD, Espy MJ, Smith TF. Serologic diagnosis of parvovirus B19 infections. Mayo Clin Proc. Nov 1993;68(11):1107-8. [Medline].
Keeler ML. Human parvovirus B-19: not just a pediatric problem. J Emerg Med. Jan-Feb 1992;10(1):39-44. [Medline].
Kirchner JT. Erythema infectiosum and other parvovirus B19 infections. Am Fam Physician. Aug 1994;50(2):335-41. [Medline].
Qari M, Qadri SM. Parvovirus B19 infection. Associated diseases, common and uncommon. Postgrad Med. Jul 1996;100(1):239-43, 246, 252. [Medline].
Further Reading
Keywords
fifth disease, erythema infectiosum, parvovirus, parvovirus infection, slapped cheek, fifth disease treatment, fifth disease symptoms, contagious, EI, human parvovirus B19, human parvovirus B19 infection, HPV B19, HPV B19 infection, aplastic anemia, lacy exanthem, Parvoviridae, polyarthropathy, hydrops fetalis




Overview: Pediatrics, Fifth Disease or Erythema Infectiosum