Parvovirus B19

Aka: Parvovirus B19, Parvovirus, Fifth Disease, Fifth Viral Exanthem of childhood, Erythema Infectiosum

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II. Epidemiology

  1. Late winter and spring outbreaks are most common
  2. Parvovirus Antibody present in >50% over age 15 years
  3. Incidence of Arthritis
    1. Children: 5% to 10% develop short-term mild Arthritis
    2. Adults: 78% develop significant joint symptoms

III. Pathophysiology

  1. Etiology: Human Parvovirus (B19)
    1. Single-stranded DNA virus
    2. Inactivated by heat,detergents (No lipid envelope)
    3. Targets P Antigen receptor on erythroid progenitors
      1. Bone Marrow
      2. Fetal liver and Umbilical Cord
      3. Peripheral blood
  2. Transmission modes
    1. Exposure to infected respiratory droplets or blood
    2. Vertical transmission from mother to fetus
  3. Transmission rates
    1. Living with infected person: 50%
    2. Teacher, daycare worker of infected children: 20-30%
  4. Transmission timing
    1. Not contagious after rash onset
    2. May Return to School once rash appears

IV. Course

  1. Incubation: 4-14 days (21 days in some cases)
  2. Infectivity: Prior to rash onset

V. Symptoms (more severe in adults)

  1. Children are often asymptomatic
  2. Prodromal symptoms (precede rash by 2 weeks)
    1. Low grade fever
    2. Gastrointestinal Upset
    3. Coryza
    4. Headache
    5. Pharyngitis
  3. Subsequent symptoms
    1. Pruritic exanthem in children (see below)
    2. Myalgia and Arthralgia (see below)

VI. Signs: Rash (more common in children)

  1. Stage 1 (onset within 2 weeks of prodromal symptoms)
    1. Cheek erythema ("Slapped Cheek") appearance on face
    2. Circumoral pallor
    3. Facial erythema spares the chin and periorbital region
  2. Stage 2 (follows facial rash by 1-4 days)
    1. Lacy-reticular maculopapular (blotchy) rash
    2. Involves trunk and extremities for 1-6 weeks
    3. Rash is pruritic
  3. Provocative factors (may result in recurrence)
    1. Sunlight exposure
    2. Heat
    3. Exercise

VII. Signs: Polyarthralgia or Polyarthritis

  1. Incidence in Parvovirus infection
    1. Children: 8%
    2. Adults: 60% (twice as likely in women than men)
  2. Rheumatoid-like joint involvement
    1. Hand involvement (most common in adults, bilateral)
      1. Metacarpophalangeal joints (MCP joints)
      2. Proximal interphalangeal joints (PIP joints)
    2. Wrist involvement
    3. Leg Involvement (most common in children)
      1. Knee involvement (82% of children)
      2. Ankle Joint involvement
  3. Arthralgia and Arthritis course
    1. Onset 1-3 weeks following initial infection
    2. Improves in most patients by 2 weeks
    3. Treated with NSAIDs for analgesia
    4. Self limited course in 90% of patients
    5. Prolonged Arthritis in 10% may last up to 10 years
    6. Morning stiffness
  4. Associated conditions
    1. Rheumatoid Arthritis
    2. Systemic Lupus Erythematosus

VIII. Differential Diagnosis

  1. Rubella
  2. Atypical Rubeola
  3. Drug-induced rashes
  4. Other Viral Exanthem

IX. Labs: Adults with persistent Polyarthritis

  1. Anti-B19 IgM Antibody
    1. Test Sensitivity: 89%
    2. Test Specificity: 99%
    3. Elevated for 2-3 months after acute infection
  2. Parvovirus DNA by PCR testing
    1. Similar sensitivity to IgM testing
    2. Indicated in aplastic crisis or if Immunocompromised
    3. Persistence suggests chronic Parvovirus infection
  3. Peripheral Blood Smear or Bone Marrow findings
    1. Giant pronormoblasts
    2. Non-specific finding
  4. Variably present serologies at low to moderate titer
    1. Rheumatoid Factor (RF)
    2. Antinuclear Antibody (ANA)
    3. Anti-dsDNA
    4. Anti-ssDNA
    5. Anti-cardiolipin Antibody

X. Management: Exposure in Pregnancy

  1. Pregnant women should avoid contact with Parvovirus
    1. Risk of transmission to fetus: 30%
    2. Risk of Hydrops fetalis with findings in newborn:
      1. Severe Anemia
      2. High output cardiac failure
      3. Extramedullary hematopoiesis
    3. Risk of fetal loss (2-6%)
    4. Risk of congenital infection syndrome
      1. Rash
      2. Anemia
      3. Hepatomegaly
      4. Cardiomegaly
    5. Risk per timing of exposure in pregnancy
      1. Highest risk: Second trimester
      2. Lowest risk: First trimester
  2. Child with Erythema Infectiosum does not need isolation
    1. May attend school and daycare once rash appears
    2. Hospital isolation is not needed
  3. Evaluation and mangement post-exposure in pregnancy
    1. Labs to confirm maternal Parvovirus infection
      1. Parvovirus B19 IgM or
      2. Parvovirus B19 IgG seroconversion
    2. Monitoring pregnancy if testing positive
      1. Serial Ultrasounds weekly for 10-12 weeks
      2. Fetal hydrops present by Ultrasound
        1. Fetal blood sampling
        2. Fetal transfusion as needed

XI. Complications: General

  1. Hydrops fetalis
  2. Gloves and Socks Syndrome

XII. Complications: Parvovirus associated erythrocyte aplasia

  1. General
    1. May be life threatening
    2. Monitor closely for possible transfusion
  2. Transient aplastic crisis in chronic Anemia
    1. Sickle Cell Anemia
    2. Thalassemia
    3. Acute Hemorrhage
    4. Iron Deficiency Anemia
  3. Chronic Bone Marrow suppression in Immunocompromised
    1. Malignancy
    2. Transplant recipient
    3. Human Immunodeficiency Virus
  4. Course
    1. Typical full recovery within 2 weeks

XIII. References

  1. Klippel (1997) Primer Rheumatic Diseases, p. 201
  2. Allmon (2015) Am Fam Physician 92(3): 211-6 [PubMed]
  3. Katta (2002) Dermatol Clin 20:333-42 [PubMed]
  4. Naides (1998) Rheum Dis Clin North Am 24(2):375-401 [PubMed]
  5. Qari (1996) Postgrad Med 100(1):239-52 [PubMed]
  6. Sabella (1999) Am Fam Physician 60(5): 1455-60 [PubMed]
  7. Servey (2007) Am Fam Physician 75:373-7 [PubMed]
  8. Siegel (1996) Am Fam Physician 54(6):2009-15 [PubMed]
  9. Takahashi (1998) Int Rev Immunol 17(5-6):309-21 [PubMed]
  10. Young (2004) N Engl J Med 350:586-97 [PubMed]
  11. Ytterberg (1999) Curr Opin Rheumatol 11:275-80 [PubMed]

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Related Studies

Ontology: Erythema Infectiosum (C0085273)

Definition (MSHFRE) Infection contagieuse due au parvovirus B19 humain, survenant généralement chez des enfants d'âge scolaire et caractérisée par de la fièvre, des céphalées, des éruptions au niveau du visage, du tronc, et des extrémités. Cette infection est souvent confondue avec la rubéole.
Definition (MEDLINEPLUS)

Fifth disease is a viral infection caused by parvovirus B19. The virus only infects humans; it's not the same parvovirus that dogs and cats can get. Fifth disease mostly affects children. Symptoms can include a low fever, cold symptoms, and a headache. Then you get a red rash on your face. It looks like a "slapped cheek." The rash can spread to the arms, legs, and trunk. Adults who get it might also have joint pain and swelling.

Fifth disease spreads easily, through saliva and mucus. You can get it when an infected person coughs or sneezes. Frequently washing your hands might help prevent getting the virus. Most people become immune to the virus after having it once.

Fifth disease is usually mild and goes away on its own. However, it can be serious if you

  • Are pregnant
  • Are anemic
  • Have cancer or a weak immune system

Centers for Disease Control and Prevention
Definition (NCI) A self-limited viral infectious disorder caused by the human parvovirus B19. It affects predominantly children and is characterized by the development of a bright red skin eruption in the cheeks. It is followed by a maculopapular skin eruption in the extremities which eventually fades into a lacey pattern.
Definition (MSH) Contagious infection with human B19 Parvovirus most commonly seen in school age children and characterized by fever, headache, and rashes of the face, trunk, and extremities. It is often confused with rubella.
Concepts Disease or Syndrome (T047)
MSH D016731
ICD9 057.0
ICD10 B08.3
SnomedCT 154344005, 266193008, 34730008
English Erythema Infectiosum, Fifth Disease, Erythema infectiosum (fifth disease), Erythema infectiosum [fifth disease], FIFTH DIS, parvovirus B19 infection, parvovirus B19 infection (diagnosis), erythema infectiosum (diagnosis), erythema infectiosum (fifth disease), erythema infectiosum, fifth disease, Erythema Infectiosum [Disease/Finding], slapped cheek syndrome, Disease;Fifth, Erythema;infectiosum, parvovirus b19 infection, erythema contagiosum, slap cheek syndrome, Erythema contagiosum, Erythema infectiosum, Fifth disease, Parvovirus B19 infection, Slapped cheek syndrome, Erythema infectiosum (disorder), disease (or disorder); fifth disease, erythema; infectiosum, fifth; disease, infectiosum; erythema, ertythema infectiosum
Dutch vijfde ziekte, Parvovirus-B19-infectie, erythema infectiosum (vijfde ziekte), aandoening; vijfde ziekte, erytheem; infectiosum, infectiosum; erytheem, vijfde; ziekte, Erythema infectiosum [vijfde ziekte], erythema infectiosum, Erythema infectiosum, Vijfde ziekte
French Infection à parvovirus B19, Erythème infectieux (5ème maladie), 5e maladie, Erythème infectieux aigu, Érythème infectieux, 5ème maladie, Cinquième maladie, Mégalérythème épidémique
German fuenfte Krankheit, Erythema infectiosum (fuenfte Krankheit), kongenitale B19-Infektion, Erythema infectiosum [Fuenfte Krankheit], Erythem infektioes, Erythema infectiosum, Fünfte Krankheit, Ringelröteln
Italian Infezione da Parvovirus B19, Eritema infettivo (quinta malattia), Quinta malattia, Eritema infettivo
Portuguese Eritema infeccioso (quinta doença), Quinta doença, Infecção por parvovírus B19, Eritema infeccioso, Eritema Infeccioso, Quinta Doença
Spanish Eritema infeccioso (quinta enfermedad), Infección por parvovirus B19, Quinta enfermedad, enfermedad de Sticker, eritema contagioso, eritema infeccioso (trastorno), eritema infeccioso, quinta enfermedad, Eritema infeccioso, Eritema Infeccioso, Quinta Enfermedad
Japanese パルボウイルスＢ１９感染, 伝染性紅斑（第五病）, ﾃﾞﾝｾﾝｾｲｺｳﾊﾝﾀﾞｲｺﾞﾋﾞｮｳ, ﾀﾞｲｺﾞﾋﾞｮｳ, ﾃﾞﾝｾﾝｾｲｺｳﾊﾝ, ﾊﾟﾙﾎﾞｳｲﾙｽB19ｶﾝｾﾝ, 紅斑-伝染性, Sticker病, スティーカー病, リンゴ病, 伝染性紅斑, 林檎病, 流行性巨大紅斑, 第5病, 輪状風疹, りんご病, シュティッカー病, スティッカー病, 第五病
Swedish Erythema infectiosum
Czech erythema infectiosum, Erythema infectiosum, Erythema infectiosum (pátá nemoc), Pátá nemoc, Infekce způsobená parvovirem B19, pátá dětská nemoc, 5. dětská nemoc, infekční zarudnutí, pátá nemoc
Finnish Pikkurokko
Russian ERITEMA, VYZVANNAIA INFEKTSIEI, PIATAIA BOLEZN', ERITEMA INFEKTSIONNAIA, ПЯТАЯ БОЛЕЗНЬ, ЭРИТЕМА, ВЫЗВАННАЯ ИНФЕКЦИЕЙ, ЭРИТЕМА ИНФЕКЦИОННАЯ
Korean 전염성 홍반 [제5병]
Polish Choroba piąta, Choroba Stickera, Rumień zakaźny
Hungarian Parvovirus B19 fertőzés, Erythema infectiosum (ötödik betegség), Ötödik betegség, erythema infectiosum
Norwegian 5. barnesykdom, Femte barnesykdom, Erythema infectiosum
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Parvoviral infections (C0851896)

Concepts Disease or Syndrome (T047)
Italian Infezioni da Parvovirus
Japanese パルボウイルス感染, ﾊﾟﾙﾎﾞｳｲﾙｽｶﾝｾﾝ
Czech Infekce způsobené parvoviry
English Parvoviral infections
Hungarian Parvovírusos fertőzések
Portuguese Infecções a parvovírus
Spanish Infecciones por parvovirus
Dutch parvovirusinfecties
French Infections à Parvovirus
German Parvovirus-Infektionen
Derived from the NIH UMLS (Unified Medical Language System)

Related Topics in Viral Infection

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