History
Common symptoms of parvovirus B19 (B19V) infection include a mild nonspecific prodromal illness that may consist of fever (15-30% of patients), malaise, headache, myalgia, nausea, and rhinorrhea; typically beginning 5-7 days after initial infection. [8, 28] These symptoms correspond to the initial viremia and dissipate in 2-3 days. [5] Approximately 1 week later, a bright red macular exanthem appears on the cheeks and is often associated with circumoral pallor. [9, 5] A diffuse maculopapular rash can appear 1-4 days later and fades to a lacy erythematous rash, which may be pruritic and may spread gradually toward the distal extremities. Most seropositive patients have no history of this classic biphasic illness. The clinical symptoms widely vary, and the classic "slapped cheek" rash is much more common in young children. [8] More recently, parvovirus B19 has been recognized as a cause of atypical rash illness in adults, [29] as well as a host of less common manifestations. [30]
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The cause of parvovirus B19 rash is believed to be immunologically mediated, and the rash corresponds to the appearance of immunoglobulin M (IgM) in the serum. This signals the clearance of viremia. Recurrence of the rash (lasting for weeks or more) may be provoked by sunlight, stress, or exercise and does not indicate relapsed infection. [2, 5]
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Alternatively, parvovirus B19 infection may manifest with purpuric rash, erythema multiforme, or pruritus of the soles of the feet. Parvovirus B19 may cause a papular-purpuric "gloves-and-socks" syndrome (PPGSS), which manifests as an erythematous exanthem of the hands and feet with a distinct margin at the wrist and ankle joints. It is mainly seen in young adults and initially presents with painful erythema and induration of the hands and feet. Less commonly, the penis, vulva, thighs, cheeks, and elbows may be involved. This syndrome occurs exclusively with parvovirus B19 infection and is an uncommon manifestation. The skin changes may progress to petechia, purpura, and bulla with skin sloughing. PPGSS usually resolves in 1-3 weeks without scaring. [5, 6, 31, 32, 33]
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Transient small joint arthropathy may be the main clinical presentation of parvovirus B19 in adults. Most have some joint pain, but few progress to frank arthritis. In general, the timing of joint symptoms coincide with the expected onset of rash in children. Arthritis usually improves in 1-3 weeks but may persist for months. Parvovirus B19 infection is not associated with chronic degenerative arthritis. [8, 2, 6] Less than 10% of children experience arthropathy; however, in those who do, the knees are most commonly involved. [9]
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Rarely, parvovirus B19 infection manifests as myocarditis, vasculitis, glomerulonephritis, or encephalitis. B19V infection has been reported in association with idiopathic thrombocytopenia purpura, Henoch-Schönlein purpura, and pseudoappendicitis. It has also been reported to precipitate hemophagocytic syndrome. [5, 8, 2, 11] In rare cases, parvovirus B19 has been implicated in fatal myocarditis in transplant patients, [17] and has been implicated as a cause of endothelial dysfunction in patients with diastolic dysfunction. [34]
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Neurologic manifestations associated with parvovirus B19 infection widely vary. [5] Peripheral nervous system involvement such as neuropathy may be seen more frequently in older immunocompetent individuals. CNS involvement, including meningitis, encephalitis, and seizure, has been demonstrated in younger children and immunocompromised patients. [35]
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Many individuals may experience asymptomatic or unrecognized infection. [5]
Physical
Parvovirus B19 infection may be indistinguishable from other viral illnesses in the absence of the classic exanthem.
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Children are often febrile, but their appearance is nontoxic and the prodrome is nonspecific.
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Patients with aplastic crisis have pallor and tachycardia secondary to anemia. Children with aplastic crisis usually do not have a rash. [9] The absence of rash may result from prolonged viremia and lack of anti–parvovirus B19 IgM. Another hypothesis is that patients in aplastic crisis often receive blood transfusions, and any rash may be attributed to a transfusion reaction.
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A friction rub may be audible if pericarditis is present. Benign flow murmurs are common in anemic children with tachycardia. Patients with myocarditis or severe anemia may present with physical findings of heart failure.
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The small joints of the hands, feet, elbows, and knees may exhibit signs of arthritis.
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Painful pruritic papules and purpura may be present on the hands and feet as part of PPGSS.
Causes
Classic fifth disease, aplastic crisis, and PPGSS are caused almost exclusively by parvovirus B19. This virus, distributed worldwide, infects only humans. Transmission occurs via vertical transmission (birth), large droplet respiratory secretions, transfusion of blood products, and percutaneous exposure to blood. [9, 28]
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Parvovirus B19 has been spread by blood products, such as intravenous immunoglobulin (IVIG), nonrecombinant clotting factors, platelets, and, to a lesser extent, packed RBCs. Because the virus lacks an outer lipid envelope and the genome is very stable, it is extremely resistant to heat, cold, and solvents. Since 2002, makers of plasma-derived products have screened for parvovirus B19. [2]
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An investigation of parvovirus B19–seronegative recipients of blood components from donors who were positive for parvovirus B19 DNA using polymerase chain reaction (PCR) failed to demonstrate any evidence of transmission when the donors viral loads were below 106 IU/mL. [36] The authors concluded that screening of packed RBC (PRBC) transfusions may not be necessary.
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Note the right side of this boy's face displaying signs of erythema infectiosum, or Fifth disease. Image courtesy of CDC.
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Elementary school child with Fifth Disease. Image courtesy of CDC.
