Derm Dx: Malar rash on the cheeks

Erythema infectiosum, or Fifth disease, is a viral infection caused by human parvovirus B19. This condition is most common in school-aged children and is less frequently diagnosed in adults.1,2 Outbreaks usually occur in late winter and early spring. The virus is...

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Erythema infectiosum, or Fifth disease, is a viral infection caused by human parvovirus B19. This condition is most common in school-aged children and is less frequently diagnosed in adults.^1,2 Outbreaks usually occur in late winter and early spring. The virus is spread through respiratory droplets and has high secondary infection rates among household contacts.³

Most cases of parvovirus B19 infection are asymptomatic.⁴ The most common clinical presentation is that of Fifth disease in children which is characterized by the classic “slapped cheek” rash.² Symptoms will typically begin 1 to 2 weeks after exposure to the virus with a prodrome of low-grade fever, headache, and coryza.  

This is followed shortly thereafter by the appearance of an erythematous malar rash with circumoral pallor often associated with a reticulated lace-like rash on the trunk and extremities. The rash in adults may be polymorphous in nature and difficult to visualize on dark skin.^2,5

At the onset of the rash patients typically feel well because viremia has resolved. Most cases are short-lived. However, recurrences may occur months after the primary episode.^6,7

Although benign in children, infection with parvovirus has been linked to aplastic anemia and, in pregnant females, to miscarriage or hydrops fetalis in the fetus.^8,9  

The rash associated with parvovirus infection is likely caused by immune complex deposition in the skin and equivocal cases can be confirmed with IgM or PCR assay.^2,10

Megha D. Patel, is a student at the Commonwealth Medical College, Scranton, Pennsylvania.

Stephen Schleicher, MD, is an associate professor of Medicine at the Commonwealth Medical College and an Adjunct Assistant Professor of Dermatology at the University of Pennsylvania Medical College. He practices dermatology in Hazleton, Pennsylvania.

References

1. Anderson LJ. The Role of parvovirus B19. Pediatr Infect Dis J. 1987;6(8):711.
2. Young NS, Brown KE.  Mechanisms of Disease: Parvovirus B19. NEJM. Feb 2004; 350(6): 586-597.
3. Chorba TL, Coccia P, Holman RC, et al. The role of parvovirus B19 in aplastic crisis and erythema infectiosum (Fifth disease). J Infect Dis 1986;154:383-93.
4. Woolf AD, Campion GV, Chishick A, et al. Clinical manifestations of human parvovirus B19 in adults. Arch Intern Med 1989; 149:1153-6.
5. Mage V, Lipsker D, Barbarot S, et al. Different patterns of skin manifestations associated with parvovirus B19 primary infection in adults. J Am Acad Dermatol. 2014 Jul;71(1):62-9
6. Lindblom A, Isa A, Norbeck O, Wolf S, Johansson B, Broliden K, Tolfvenstam T. Slow clearance of human parvovirus B19 viremia following acute infection. Clin Infect Dis. 2005;41(8):1201.
7. Lowry SM, Brent LH, Menaldino S, Kerr JR. A case of persistent parvovirus B19 infection with bilateral cartilaginous and ligamentous damage to the wrists. Clin Infect Dis. 2005;41(4):e42.
8. Risks associated with human parvovirus B19 infection. MMWR Morb Mortal Wkly Rep 1989;38:81-8, 93-7.
9. Human parvovirus B19 infections in United Kingdom 1984-86. Lancet 1987;1:738-9.
10. Toppinen M, Norja P, Aaltonen LM, et al. A new quantitative PCR for human parvovirus B19 genotypes. J Virol Methods. 2015; 218:40-5