Virus

Parvovirus B19

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

  • 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
  • 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
  • Course
  1. Incubation: 4-14 days (21 days in some cases)
  2. Infectivity: Prior to rash onset
  • 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)
  • 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
  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
  • Differential Diagnosis
  1. Rubella
  2. Atypical Rubeola
  3. Drug-induced rashes
  4. Other Viral Exanthem
  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
  • 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
  • Complications
  • General
  1. Hydrops fetalis
  2. Gloves and Socks Syndrome
  • 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
  • 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]