Infectious Disease Book

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Parvovirus B19Aka: Parvovirus, Fifth Disease, Second Viral Exanthem of childhood, Erythema Infectiosum

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  1. 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
  2. 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
  3. Course
    1. Incubation: 4-14 days (21 days in some cases)
    2. Infectivity: Prior to rash onset
  4. 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)
  5. 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
    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
      1. Sunlight exposure
      2. Heat
      3. Exercise
  6. 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
  7. Differential Diagnosis
    1. Rubella
    2. Atypical Rubeola
    3. Drug-induced rashes
    4. Other Viral Exanthem
  8. 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
  9. 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
      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
  10. Complications: General
    1. Hydrops fetalis
    2. Gloves and Socks Syndrome
  11. 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
  12. References
    1. Klippel (1997) Primer Rheumatic Diseases, p. 201
    2. Katta (2002) Dermatol Clin 20:333
    3. Naides (1998) Rheum Dis Clin North Am 24(2):375
    4. Qari (1996) Postgrad Med 100(1):239
    5. Sabella (1999) Am Fam Physician 60(5):1455
    6. Servey (2007) Am Fam Physician 75:373
    7. Siegel (1996) Am Fam Physician 54(6):2009
    8. Takahashi (1998) Int Rev Immunol 17(5-6):309
    9. Young (2004) N Engl J Med 350:586
    10. Ytterberg (1999) Curr Opin Rheumatol 11:275

Erythema Infectiosum (C0085273)

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.
ConceptsDisease or Syndrome (T047)
ICD9057.0, 057.0
MSHD016731
EnglishErythema contagiosum, Erythema Infectiosum, FIFTH DIS, Fifth disease, Parvovirus B19 infection, Slapped cheek syndrome
Spanishenfermedad de Sticker, eritema contagioso, eritema infeccioso, quinta enfermedad
Parent ConceptsOther viral exanthemata NOS (C0153061), Erythema (C0041834), Skin Diseases, Viral (C0162628), Disease due to Parvoviridae (C0276275), Viral diseases with exanthemata NOS (C0153062)
SourcesCOSTAR, DXP, ICD9CM, MEDLINEPLUS, MSH, MTHICD9, NDFRT, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)


Parvovirus (C0086776)

Definition (MSH)A genus of the family PARVOVIRIDAE, subfamily PARVOVIRINAE, infecting a variety of vertebrates including humans. Parvoviruses are responsible for a number of important diseases but also can be non-pathogenic in certain hosts. The type species is MINUTE VIRUS OF MICE.
Definition (NCI)A family of very small DNA viruses containing a single linear molecule of single-stranded DNA and consisting of two subfamilies: parvovirinae and densovirinae. They infect both vertebrates and invertebrates.
ConceptsVirus (T005)
MSHD017992
EnglishGenus Parvovirus, Parvoviridae, Parvovirus, Parvovirus group, Parvoviruses, Picodnavirus, PV - Parvovirus
Spanishgenero Parvovirus, grupo parvovirus, parvovirus, picodnavirus
Parent ConceptsParvoviridae (C0030617), Parvovirinae (C0376483), ssDNA viruses (C1002566)
SourcesAOD, CSP, LNC, MSH, MTH, NCBI, NCI, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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