Parvovirus B19 (Erythema Infectiosum, Fifth Disease)
Parvovirus B19 (Erythema Infectiosum, Fifth Disease): Excerpt from The 5-Minute Pediatric Consult
J. Nadine Gracia, MD
Parvovirus B19 - BASICS
Parvovirus B19 - description
Parvovirus B19 (B19) is a common viral infection of school-aged children that is most commonly associated with an erythematous macular rash in a patient whose appearance remains well. B19 is a single-stranded DNA virus, one of the smallest of the human viruses, that was 1st isolated from asymptomatic blood donors in 1975.
Parvovirus B19 - general prevention
- In the hospital environment, secondary attack rates approaching 40% were reported in susceptive health care workers exposed to 2 children with sickle cell disease and unsuspected B19 infections.
- In response, all patients with suspected aplastic crisis secondary to B19 should be placed in contact isolation.
- No measures are needed for normal hosts with rash. In addition, pregnant teachers who are at risk for infections should consider a leave of absence during community outbreaks of B19.
Parvovirus B19 - epidemiology
- Most B19 infections occur in school-aged children.
- Route of spread includes exposure to:
- Nasal secretions
- Aerosolized large-droplet respiratory secretions
- Blood (1,011 virions/mm or serum in patients with hereditary hemolytic anemias)
Parvovirus B19 - incidence
Attack rates: From 15–60% of susceptibles (i.e., seronegative) will become infected on exposure.
Parvovirus B19 - prevalence
Seroprevalence of B19 IgG antibodies:
- >5 years old: 2–9%
- 5–18 years old: 15–35%
- Adults: 30–60%
- Elderly: 90%
Parvovirus B19 - pathophysiology
- Parvovirus B19 inhibits erythropoiesis by lytically infecting RBC precursors in the bone marrow and is associated with a number of different diseases ranging from benign to severe.
- There is no practical in vitro system for isolation or culture of the virus.
Parvovirus B19 - etiology
Exposure to virus
Parvovirus B19 - associated conditions
- Aplastic crisis secondary to B19 in patients with hereditary hemolytic anemias or any condition that shortens the RBC life span, such as sickle cell disease or spherocytosis, may cause severe anemia.
- Fifth disease or erythema infectiosum caused by B19 occurs in up to 35% of school-aged children.
- Human parvovirus arthropathy, symmetric joint pain, and swelling, especially of the hands, knees, and feet, is seen in adults much more frequently than in children; among women with B19 infection, 80–100% develop polyarthritis.
- Hydrops fetalis may develop after maternal B19 infection and intrauterine involvement.
- Chronic bone marrow failure due to persistent B19 infection has been reported in immunocompromised patients.
- Extremity numbness and tingling, hemophagocytic syndrome, and Henoch-Schönlein purpura have recently been sporadically reported as being associated with B19 infection.
- Papular-purpuric gloves-and-socks syndrome is a rash localized to the hands and feet. It is associated with edema, erythema, and paresthesia.
Parvovirus B19 - DIAGNOSIS
Dependent on recognition of typical symptoms and the results of laboratory testing
Parvovirus B19 - signs & symptoms
- Asymptomatic infection may occur in ~20% of children and adults.
- Erythema infectiosum:
- The most common form of parvovirus infection recognized
- Incubation period is 4–14 days
- A brief, mild prodrome of symptoms including headache, sore throat, myalgias, and low-grade fevers often precedes the rash by 7–10 days.
- A facial rash that is erythematous (slapped cheeks) is noticed next, which spreads to the body and extremities.
- The body rash is macular erythematous and lacy appearing. It may become more intense with sunlight, heat, and exercise and may be pruritic. Occasionally, it involves the palms and soles and rarely can be papular, vesicular, or purpuric. It may last for ~7 days but can persist >20 days.
- The child is usually unaffected and remains active and playful.
- Symptoms in adults are similar although often more severe.
- During the illness, 80% of adults have arthralgias or arthritis.
- Aplastic crisis:
- Prodromal symptoms in B19-infected children with sickle cell disease or other hereditary hemolytic anemias are nonspecific and consist of fever, malaise, and headache. Rash is usually absent. Laboratory testing confirms the diagnosis.
- Lasts 7–10 days. Usually self-limited but can cause severe anemia, CHF, stroke, and acute splenic sequestration.
- Chronic marrow suppression:
- In immunocompromised patients, B19 infection may persist for months, leading to chronic anemia with B19 viremia.
- Low-grade fever and neutropenia may accompany anemia.
Parvovirus B19 - physical exam
Fifth disease:
- A facial rash that is erythematous (slapped cheeks) and spreads to the body and extremities.
- Macular erythematous and lacy-appearing body rash that may become more intense with exercise and be pruritic
- Occasionally involves the palms and soles and rarely can be papular, vesicular, or purpuric
Parvovirus B19 - tests
Parvovirus B19 - lab
- Antibodies:
- Presence of specific IgM or IgG antibodies as determined by EIA and/or detection of virus.
- In patients with symptoms of erythema infectiosum or aplastic crisis, the presence of B19-specific IgM antibodies is diagnostic. IgM- and IgG-specific antibodies are detected in 90% of such patients by 3–7 days of illness.
- B19-specific IgG antibodies persists for years, while specific IgM antibodies begin to fall 30–60 days after onset of illness.
- Polymerase chain reaction (PCR) techniques:
- Immunocompromised patients with chronic marrow may be unable to produce B19-specific IgG or IgM antibodies. In such cases, B19 viral DNA can be detected using nuclear and hybridization or PCR techniques. Such techniques are also useful for detecting infection in fetuses.
- Hematocrit and reticulocyte count in patients with aplastic crisis:
- Laboratory studies reveal reticulocytopenia, usually with counts of <1%. During the illness, the patient’s hematocrit may fall as low as 15%.
Parvovirus B19 - differencial diagnosis
B19 infection should be considered in all patients with arthritis or viral exanthems with a history and examination that is consistent.
Parvovirus B19 - TREATMENT
Parvovirus B19 - general measures
- There is no specific therapy for this infection other than supportive care.
- IV immunoglobulin therapy has been given with some success to a few patients with chronic marrow suppression secondary to B19 infection.
Parvovirus B19 - FOLLOW UP
Expected course of illness:
- During aplastic crisis, secondary to B19, the reticulocytopenia usually remains low (often <1%) for ~8 days before spontaneous recovery.
- The rash of erythema infectiosum in the child or adult may last up to 20 days. It may, at times, fade and/or intensify, depending on sunlight exposure, exercise, or body surface temperature changes (bathing).
Parvovirus B19 - prognosis
The prognosis is quite good for all manifestations of B19 infections
- In general, they require supportive care only until spontaneous recovery.
Parvovirus B19 - complications
- Parvovirus B19 during pregnancy:
- Fetal loss, intrauterine growth retardation, or hydrops fetalis may occur if the mother is infected with B19 during pregnancy.
- 50% of women are susceptible to B19 infection.
- The infection is not a teratogen to the fetus.
- Fetal death occurs in 2–6% of cases.
- The greatest risk for B19 infection to affect the fetus exists in the 1st 20 weeks of gestation.
- There is no indication for elective abortion in cases of maternal infection.
- The risk of fetal death after exposure, if antibody status is unknown, is from 0.05–1%.
- Aplastic crisis:
- Transfusions may be necessary to treat symptoms of severe anemia.
- Arthritis/Arthropathy:
- Although most cases of polyarthritis resolve within 2 weeks, persistent symptoms for months to even years (rarely) have been reported.
Parvovirus B19 - bibliography
American Academy of Pediatrics. Parvovirus B19. ln: Pickering LK, ed. 2006 Red Book: Report of the Committee on Infectious Diseases. 27th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2006.
- Anderson LJ, Tsou C, Parker RA, et al. Detection of antibodies and antigens of human parvovirus B19 by ELISA. J Clin Microbiol. 1986;24:522–526.
Bell LM. Parvovirus B19 infection: A decade of discovery. In: Long SS, Starr SE, eds. The Report on Pediatric Infectious Diseases. 1992;2:6.
- Bell LM, Naides SJ, Stoffman P, et al. Human parvovirus B19 infection among hospital staff members after contact with infected patients. N Engl J Med. 1989;321:485–491.
- Cherry JD. Parvovirus infections in children and adults. Adv Pediatr. 1999;46:245–269.
- de Jong EP, de Haan TR, et al. Parvovirus B19 infection in pregnancy. J Clin Virol. 2006;36:1–7.
- Kerr JR. Pathogenesis of human parvovirus B19 in rheumatic disease. Ann Rheum Dis. 2000;59:672–683.
- Nunoue T, Kusuhara K, Hara T. Human fetal infection with parvovirus B19: Maternal infection time in gestation, viral persistence, and fetal prognosis. Pediatr Infect Dis J. 2002;21:1133–1136.
- Smith-Whitley K, Zhao H, et al. Epidemiology of human parvovirus B19 in children with sickle cell disease. Blood. 2004;103:422–427.
- Török TJ. Parvovirus B19 and human disease. Adv Intern Med. 1992;37:431–455.
- Ware R. Human parvovirus infection. J Pediatr. 1989;114:343–348.
- Young NS, Brown KE. Parvovirus B19. N Engl J Med. 2004;350:586–597.
Parvovirus B19 - CODES
Parvovirus B19 - icd9
057.0 Parvovirus B19
Parvovirus B19 - FAQ
- Q: When may children with B19 infection return to school?
- A: Children are not infectious when the rash appears. Therefore, they may return to school or day care. The infectious period is only during the prodromal phase of illness, which is often unrecognized.
- Q: What can be done to reduce risk of fetal infection?
- A: Because B19 infections during pregnancy may result in fetal death, and B19 infections often occur in community outbreaks, fetal risks following maternal exposure to persons with recognized B19 infection are a frequent concern. Among pregnant women of unknown antibody status, the risk of fetal death after exposure to B19 is estimated to be <1.5%. Risk to the fetus appears to be greatest if the infection occurs prior to the 20th week of gestation. Pregnant teachers who are at risk for infection should consider a leave of absence during community outbreaks of B19.
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Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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