Parvovirus B19_0412 Derm Dx
A 5-year-old girl presents with a rash on her cheeks that has been present for one day. The girl’s mother reported that the rash appeared quite suddenly.
The patient is otherwise well, without fevers, upper-respiratory symptoms, arthralgias or malaise. A complete review of symptoms is negative. The girl has no sick contacts or history of recent travel. The mom states that the rash is probably an allergy to new wet wipes that she began using recently, and notes that her daughter has very sensitive skin.
On exam, the girl is afebrile, well nourished, well developed and appears nontoxic. A full body skin exam is significant only for a diffuse bright pink macular rash on her cheeks, sparing the nasal bridge. What’s your diagnosis?
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This patient has fifth disease caused by parvovirus B19. Fifth disease is also known as erythema infectiosum or slapped-cheek disease. Parvovirus is a single stranded DNA virus that causes infection worldwide. About 50% of the population develops antibodies to parvovirus B19 by the age of 15 years (indicating previous infection), and the majority of elderly adults have antibodies. Most infections are asymptomatic.
Parvovirus B19 spreads via the respiratory route. Immunoglobulin M (IgM) antibodies appear eight to 10 days after initial inoculation. Seven days after the appearance of IgM antibody, anti-B19 immunoglobulin G (IgG) appear, which coincides with the appearance of rash and arthralgia. The patient is no longer infectious by the time clinical symptoms occur (i.e. rash).
Fifth disease is most common in children aged 4 to 10 years and is characterized by the sudden onset of a bright pink- to red- macular rash on the cheeks. The rash is most intense on the malar skin below the eyes, and usually spares the eyelids and the nasal bridge. Patients are commonly asymptomatic, but on rare occasion the rash may be preceded by fever or an upper respiratory infection.
One to four days after patients with fifth disease develop the initial eruption on the cheeks the second stage of the exanthema begins, which consists of lacy pink reticulated macules on the extremities. The second stage is evanescent (meaning the rash comes and goes), lasts one to three weeks and is exacerbated by physical factors, such as heat and exercise.
Potential complications with parvovirus B19 infection include arthropathy, which is most common in adult females; aplastic crisis in patients with sickle cell disease; and acute viral myocarditis and pericarditis. In pregnant woman, infection may lead to a transplacental infection, which results in fetal demise in 5% to 9% of cases.1,2
Fifth disease diagnosis is based on clinical presentation with the typical rash on the cheeks and subsequent evanescent rash on the extremities. When definitive diagnosis is required, serum anti-B19 IgM antibodies will indicate infection within the prior two to four months.
Sixth disease, also called roseola infantum or xanthem subitum, is preceded by high fevers for four to five days. Sixth disease is caused by human herpes virus 6, a DNA virus. At de-effervescence rose-pink macules and papules appear on the trunk, neck, extremities and occasionally the face. Red papules, termed Nagayama spots, may also be present on the soft palate and uvula.
Hand-foot-and-mouth disease is characterized by vesicles on the palms and soles, in addition to oral erosions on the tongue, buccal mucosa, palate, uvula and tonsils. The rash tends to involve the dorsal hands, feet, buttocks and perineum. It is caused by cocksackievirus A16, an RNA enterovirus.
Cocksackie A16 also causes herpangina, most commonly among children aged 3 to 10 years, which consists of painful vesicles and erosions on the buccal mucosa, soft palate, uvula and tonsils, but these symptoms occur without a skin rash.
Even though the mother reported that the rash was likely a contact dermatitis to a new product she recently applied to her daughter’s sensitive skin, this case illustrates that we frequently need to ignore the history in dermatology and trust the physical exam.1, 2
Treatment and prognosis
Treatment is supportive and based on the specific clinical manifestations of parvovirus B19 infection. For common exanthems such as fifth disease disease, no treatment is required. 1, 2
Adam Rees, MD, is a graduate of the University of California Los Angeles School of Medicine and a resident in the Department of Dermatology at Baylor College of Medicine in Houston.
1. Bolognia J , Jorizzo JL, Rapini RP. “Chapter 80: Other Viral Diseases.” Dermatology. 2008; Mosby/Elsevier: St. Louis, Mo.
2. James WD, Berger TG, Elston DM et al. “Chapter 19: Viral Diseases.” Andrews’ Diseases of the Skin: Clinical Dermatology. 2006; Saunders Elsevier: Philadelphia.