Erythema Infectiosum (Fifth Disease)


Article Author:
Sean Kostolansky


Article Editor:
James Waymack


Editors In Chief:
Sisira Reddy
Dhia Kaffel
Joseph Nahas


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
5/8/2019 5:29:18 PM

Introduction

Erythema infectiosum is a common viral exanthem illness found in children. It is also known as “fifth disease” as it is 1 of the 6 most common viral rash illnesses found in children.[1] This febrile illness typically affects children 5 to 15 years old. The viral illness can also affect adults, however less commonly. Route of transmission is primarily via droplets from respiratory secretions and can spread via blood exposure. This is a common illness found in the spring months and early summer months. Symptom control and supportive management are the basis for treatment of erythema infectiosum, but complications such as aplastic crisis or hydrops fetalis during pregnancy must be considered.

Etiology

Parvovirus B19 causes erythema infectiosum. This is a non-enveloped, single-stranded, DNA virus belonging to the Parvoviridae family.[2]

Epidemiology

Erythema infectiosum occurs worldwide. It more commonly occurs in school-age children who are 5 to 15 years old. It can affects adults but less frequently. This infection is commonly seen in the spring months of the year.[3]

Parvovirus B19 infection in pregnant patients can have severe fetal complications. These complications include miscarriage, intrauterine death, and hydrops fetalis.[4] The risk of fetal loss after acute infection is approximately 5%. Mothers in their second trimester of pregnancy are at greatest risk of developing complications from parvovirus B19, but cases have been reported at all points of pregnancy.

Patients with sickle-cell or other chronic hemolytic diseases can be more severely affected than other populations.[5] Infection by parvovirus B19 destroys reticulocytes. This causes a decrease or transient halt in erythropoiesis. Such individuals can develop an aplastic crisis and lead to severe anemia. Often, these patients will be much more ill-appearing with fevers, malaise, and lethargy. Patients with aplastic crisis will have pallor, tachycardia, and tachypnea from the severe anemia.

Pathophysiology

Parvovirus B19 is transmitted most commonly through respiratory droplets into cells in the respiratory tract. Transmission can also occur via blood exposure. Viremia from parvovirus B19 exposure usually occurs within 5 to 10 days, and the patient remains contagious approximately 5 days after viremia occurs. If an immunocompetent host becomes infected, there can be a range of symptoms. This can range from no symptoms to non-specific flu-like symptoms to the classic symptoms of facial rash and arthralgias. When a patient has symptoms of arthralgias and exanthem, they are no longer contagious and are not at risk to spread the virus. When parvovirus B19 infects a fetus, hydrops fetalis occurs because the virus affects red blood cell production in the fetus which, in turn, causes high output heart failure.

History and Physical

The most common and classic presentation of erythema infectiosum is a mild febrile illness with rash. Beginning symptoms of infection can include fever, malaise, myalgias, diarrhea, vomiting, and headache. After initial viremia, the classic erythematous malar rash involving the cheeks with surrounding oral pallor develops. This rash does not develop early in the disease process. The rash is classically characterized as a “slapped-cheek rash” and may be the only clinical diagnostic finding in this disease process. This facial rash can last 4 to 5 days. At the time the facial rash develops, the patient usually feels well, and the viremia has resolved. This rash is thought to be immune-mediated. Days after the facial rash develops, a maculopapular rash usually develops on the trunk and limbs. This rash in nonpruritic and usually lasts about 1 week. The rash may also have a lacy or reticular appearance as it starts to resolve. The reticular rash is often present more on the extensor surfaces. The palms of the hands and soles of the feet are typically not affected.[6]

The course of infection can also present with arthralgias. Joint symptoms are thought to be immune-mediated, and they are more common in adults than children. Women are more affected by joint symptoms than men. The affected joints are usually symmetric. Commonly affected joints include hands, feet, wrist, knees, and feet. Patients will most often complain of joint stiffness. The affected joints show no signs of physical joint destruction from the virus. Joint involvement is usually later in the disease course as well. These joint symptoms typically resolve after about 3 weeks of symptom onset.  When joint symptoms are present, the patient is not considered infectious or contagious.

Immunocompromised individuals typically do not show manifestations of rash and joint symptoms due to the belief that these are immune-mediated, and they would not have an adequate immune response to this infection for these symptoms to develop. Patients who are immunocompromised may develop chronic parvovirus B19 infection which can lead to neutropenia, thrombocytopenia, or complete bone marrow suppression.

Evaluation

Diagnosis of parvovirus B19 infection is usually not warranted due to the self-limiting progression of the disease and typical mild symptoms. Testing can be obtained via bloodwork for specific antibodies. Testing for specific parvovirus B19 IgM antibody can confirm acute infection on serology. IgM antibodies can usually be found within 7 to 10 days of virus exposure. These can remain measurable for 2 to 3 months after exposure to the virus. IgG antibodies will start to rise about 2 weeks after viral exposure, and the patient will confer immunity as these will then be measurable for life.[7]

This testing can be useful in patients with aplastic crisis diagnosis to confirm and help support causation from acute parvovirus B19 detection. Testing for IgG antibodies can be common in prenatal testing for women to look for immunity status to parvovirus B19 to access the risk of potential congenital disabilities.

Treatment / Management

The disease process is typically self-limiting. Symptom control and supportive management are the basis for treatment of erythema infectiosum. Use acetaminophen and/or NSAIDs for fever control, arthralgias, and headache, if present. If an aplastic crisis is found on workup, then serial hemoglobin/hematocrit testing should be performed with red blood cell transfusions, as needed, throughout viral infection. If a mother is found to have acute parvovirus B19 infection early in pregnancy, she will need close follow-up with her obstetrician for serial ultrasounds and to monitor for fetal complications and hydrops fetalis.

Differential Diagnosis

Many other viral exanthems can be included in the differential diagnosis of erythema infectiosum including measles, rubella, roseola, and scarlet fever. In adults, when arthralgias are more common, differential diagnosis can include influenza and mononucleosis. Non-infectious causes such as drug hypersensitivity, rheumatoid arthritis, and juvenile idiopathic arthritis should also be considered. The arthritic diagnoses on differential can be excluded once joint pain/stiffness resolves after about 3 weeks of symptom onset.[8]

Prognosis

Symptoms of erythema infectiosum are usually self-limited in immunocompetent hosts. These symptoms are typically mild, and some patients may be asymptomatic. In patients who are immunocompromised or in patients with hematologic disorders, symptoms can be more severe. Chronic infection and chronic anemia can occur in immunocompromised individuals. Acute infection and exposure to a fetus can be fatal. Fetal death risk is highest in infected pregnant patients under 20 weeks gestational age.[9]

Pearls and Other Issues

  • This is a common viral exanthem illness found in children in the spring months.
  • Classic erythematous rash on the cheeks and perioral sparing/pallor is the diagnostic rash for erythema infectiosum.
  • Care must be taken in individuals with suspected infection who are pregnant due to the risk of hydrops fetalis.
  • Care must be taken in individuals with suspected infection who have sickle cell disease due to the risk of aplastic crisis.

Enhancing Healthcare Team Outcomes

Erythema infectiosum is a benign viral illness in children and often managed by the pediatrician, emergency department physician, internist and the nurse practitioner. However, if the infection is diagnosed in a pregnant female an obstetric consult should be made. The virus is known to cause aplastic crises and hydrops fetalis. The pregnant female will need monitoring until delivery. 

For healthy people, the outcomes are excellent.


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Erythema Infectiosum (Fifth Disease) - Questions

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A 3-year-old child is seen in the clinic with a low-grade fever, cough, and malaise. The mother says that he has been ill for the past 3 days. Examination reveals a red rash over the cheeks but not present in the nasal and periorbital area. What is the most likely cause?



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A four-year-old child has had a fever and muscle aches for several days. He is better now but has a rash on both cheeks. Which of the following is the most likely cause of these findings?



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A 40-year-old female develops polyarticular arthritis and diffuse, mild abdominal pain. On exam, a bright red, raised erythematous rash is noted on both cheeks. If positive, which of the following tests would be most helpful for making a diagnosis?



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A child presents with an erythematous, "slapped-cheek" rash. What pathogen most likely is the cause?

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Erythema infectiosum (Fifth disease) is sometimes associated with which of the following?



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Which of the following can be associated with erythema infectiosum (Fifth disease)?



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Which of the following is the most likely pathogen causing Fifth disease?



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Erythema infectiosum (EI), also termed fifth disease, is associated with:



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Which of the following is the disease that resembles a "slapped cheek" causing a red rash on the face?



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A 26-year-old female approximately 15 weeks gestational age presents with five days history of fever and headache. Today she complains of stiff joints. She reports she was around her nephew who had fever followed by a red rash on his cheeks that had a slapped-cheek appearance. The fetus is at risk for what complication?



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An eight-month-old male presents to the emergency department with a complaint of rash. The mother states seven days ago he had symptoms of fever, headache, myalgias. Two days ago he developed a red rash on his cheeks and now he is starting to have a rash on his trunk. On exam, he has a rash that resembles a “slapped-cheek” appearance and a lacy maculopapular rash on his trunk. What is his most likely diagnosis?



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A mother brings her six-year-old female daughter with a rash. She states her symptoms started seven days ago with fever and myalgias. Two days ago she developed a rash on her face and on exam she has and erythematous rash localized to her cheeks and circumferential pallor to her lips. She is concerned about spread to infection to her other children. For how long is the child contagious?



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A twelve-year-old male is brought in with fever, tachycardia, and tachypnea. The child has a temperature of 38.4 C, heart rate 128 bpm, respiratory rate 30/minute, pulse oximetry 96%, and blood pressure 98/68 mmHg. The mother states that he has sickle-cell disease. The mother also states earlier in the week his sister had had fever followed by a red rash on her cheeks that had a slapped-cheek appearance. What is the child at risk for developing?



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A 30-year-old female presents to the emergency department with a complaint of muscle stiffness. She has no medical problems. She states she developed a fever and headache earlier in the week, that has since resolved. Now she has joint stiffness in her hands and feet. She states her five-year-old son had a fever followed by a red rash on his cheeks last week. He did not have any complaint of joint stiffness. What is the most likely cause of her symptoms?



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Erythema Infectiosum (Fifth Disease) - References

References

Mende M,Sockel K, Parvovirus B19 Infection. The New England journal of medicine. 2018 Dec 13;     [PubMed]
Rogo LD,Mokhtari-Azad T,Kabir MH,Rezaei F, Human parvovirus B19: a review. Acta virologica. 2014;     [PubMed]
Vafaie J,Schwartz RA, Erythema infectiosum. Journal of cutaneous medicine and surgery. 2005 Aug;     [PubMed]
Kontomanolis EN,Fasoulakis Z, Hydrops Fetalis and THE Parvovirus B-19. Current pediatric reviews. 2018;     [PubMed]
Borsato ML,Bruniera P,Cusato MP,Spewien KE,Durigon EL,Toporovski J, [Aplastic crisis in sickle cell anemia induced by parvovírus B19] Jornal de pediatria. 2000 Nov-Dec;     [PubMed]
Allmon A,Deane K,Martin KL, Common Skin Rashes in Children. American family physician. 2015 Aug 1;     [PubMed]
Molenaar-de Backer MW,Russcher A,Kroes AC,Koppelman MH,Lanfermeijer M,Zaaijer HL, Detection of parvovirus B19 DNA in blood: Viruses or DNA remnants? Journal of clinical virology : the official publication of the Pan American Society for Clinical Virology. 2016 Nov;     [PubMed]
Gable EK,Liu G,Morrell DS, Pediatric exanthems. Primary care. 2000 Jun;     [PubMed]
Valentin MN,Cohen PJ, Pediatric parvovirus B19: spectrum of clinical manifestations. Cutis. 2013 Oct;     [PubMed]

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