PPGSS 1_0913 Derm Dx
PPGSS 2_0913 Derm Dx
A 22-month-old patient presents with a rash on his palms and soles. His mother states the eruption began abruptly two days ago. She describes the skin as erythematous, “beet red,” and says the skin feels very rough, thick and slightly warm.
The child is otherwise healthy and takes no medications. The mother thinks that the child may have had a slight fever initially. On exam today, the patient is afebrile. The patient has confluent pink-purplish patches on his palms and soles.
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Papular-purpuric gloves and socks syndrome (PPGSS) is viral exanthem most strongly associated with human parvovirus B19 infection. PPGSS classically appears as rapidly progressing erythema of the hands and feet with margins ending abruptly at the wrist and ankles. Patients may describe these changes as painful and intensely pruritic with accompanying edema.
The characteristic papular-purpuric lesions develop on the dorsal and volar aspects of the hands and feet after initial skin changes. Oral manifestations have been known to occur including erosions, vesiculopustules and petechiae involving the hard and soft palate, tongue and buccal mucosa.
PPGSS occurs most often in the spring following the seasonal pattern of peak B19 infection. Patients of all ages are affected, but most cases have been reported in teenagers and young adults. In children the average age at infection is 23 months.
Skin findings may present during or after the development of systemic symptoms including malaise, low-grade fever, fatigue, myalgias, arthralgias and lymphadenopathy. Generally the entire syndrome resolves within one to two weeks; however, in younger children the syndrome may last as long as five weeks.
Fifth disease, also known as erythema infectiousum, is the most common cutaneous manifestation of parvovirus B19 infection. Fifth disease typically occurs in younger patients between 4 and 10 years of age, and lasts between one to three weeks. The initial stage occurs seven to 10 days after the onset of mild prodromal symptoms, with the development of bright red macular erythema of the cheeks (known as slapped-cheek appearance) that spares the nasal bridge and circumoral regions. One to four days later the second stage develops with erythematous macules and papules on the extremities and trunk.
Roseola infantum is caused by human herpes virus 6 (HHV-6) and occurs most often between 6 months and 3 years of age. It begins with a high fever that lasts three to five days and subsequent development of rose pink macules on the trunk, neck, proximal extremities and sometimes face as the fever resolves.
Gianotti-crosti syndrome is a self-limited cutaneous response to a number of infections, most notably Epstein-Barr virus (EBV) and hepatitis B virus. Rash is classically preceded by an upper respiratory tract infection with abrupt development of skin-colored to pink-red, edematous papules on the face, buttocks and extensor surfaces of the arms and legs. The lesions are typically asymptomatic, and the trunk is usually spared.
Diagnosis & Treatment
PPGSS diagnosis is made on the basis of clinical findings. The majority of parvovirus B19 infections are mild and do not require extensive work-up, thereby negating the need for confirmatory testing. If required, the diagnosis can be confirmed with anti-B19 IgM antibody detection. Positive results indicate parvovirus B19 infection within the past two to four months.
The treatment of PPGSS is reassurance, since this is a benign and self-limited syndrome.
William D. Longhurst is a senior medical student at the University of North Dakota School of Medicine and Health Sciences.
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 also in Houston.
- Bolognia J, Jorizzo JL, Rapini RP. “Chapter 81: Other Viral Diseases.” Dermatology. St. Louis, Mo.: Mosby/Elsevier, 2008.
- Cennimo DM, Dieudonne A. “Parvovirus B19 Infection.” Medscape. 2012 Mar 30. Available at http://emedicine.medscape.com/article/961063-overview.
- Hashimoto H, Yuno T. “Parvovirus B19-associated purpuric-petechial eruption.” J Clin Virol. 2011; 52(3): 269-71.
- James WD, Berger TG, Elston DM et al. “Chapter 19: Viral Diseases.” Andrews’ Diseases of the Skin: Clinical Dermatology. Philadelphia: Saunders Elsevier, 2006