History

Fact Explanation
Rash The rash is the most important clinical finding in erythema infectiosum. Initially rash appears on the face, cheeks are red in appearance, thus is known as the "slapped cheek" appearance. [1] This is followed by a rash on the limbs and trunk. [1] The rash usually has an appearance of a lace pattern on the trunk and limbs. This lace pattern is due to the erythematous macules and papules giving it a reticular appearance. [2]
Fever Erythema infectiosum is caused by parvovirus B19 infection. [1] It is also known as the 'fifth disease'. Fever may be a presenting feature, but usually it is of a mild degree.
Headache One of the presenting symptoms in the initial stage. [11]
Rhinnorhoea Erythema infectiosum is usually transmitted via droplet inhalation. [5] This may be one of the presenting symptoms of erythema infectiosum.
Red eye These patients may have features of conjunctivitis [2] and can present with red eye, itching, and lacrimation.
If complicated with meningitis These patients can develop serous meningitis during the course of the disease. [3] They can have fever, pain on retraction of the neck, and drowsiness.
If complicated with aplastic anaemia Aplastic anaemia is one of the major systemic involvement in erythema infectiosum, [5] specially in patients with haematological disorders such as hereditary haemolytic anaemias [8]. They can present with recurrent infections and bleeding manifestations due to low platelet and white cell count.
If complicated with arthritis Sometimes patients can get arthropathies due to erythema infectiosum. [5] It is shown that parvovirus infection trigger an arthropathy. [9] They will have joint pain, swelling and stiffness involving the bilateral hands, feet and knee joints. It may progress to a state of chronic arthritis.[6]
If complicated with glomerulonephritis Glomerulonephritis is a rare complication of erythema infectiosum. They can present with haematuria, frothy urine and generalized body swelling. [12]
High risk groups Patients with hematologic diseases, immunosuppression(organ transplant recipients, long-term steroid usage, acquired immunodeficiency syndrome etc.) and pregnant mothers are considered as high risk groups as they are vulnerable to get complications with erythema infectiosum. [4]
Complications during pregnancy Pregnancy is a high risk condition, where they can develop hydrops fetalis [5] and even intrauterine death due to transplacental transmission of infection.
Can be complicated by acute liver failure This is a rare complication of erythema infectiosum [10]. If complicated with acute liver failure patients can present with yellowish discolouration of the eyes and right hypochondrial pain.
Raynaud's phenomenon This is due to the endothelial damage which causes platelet activation and vasoconstriction. Studies have shown that this mechanism is immune-mediated. [7]
References
  1. VAFAIE J, SCHWARTZ RA. Erythema infectiosum. J Cutan Med Surg [online] 2005 Aug, 9(4):159-61 [viewed 23 June 2014] Available from: doi:10.1007/s10227-005-0101-8
  2. SCHARRE JE, VEITH J. Conjunctivitis associated with fifth disease in a child: a case report. J Am Optom Assoc [online] 1996 Dec, 67(12):763-6 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9286318
  3. CANOVIć P, RAVIć-NIKOLIć A. [Acute serous meningitis in a patient with erythema infectiosum]. Vojnosanit Pregl [online] 2006 Jan, 63(1):73-5 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16471253
  4. KATTA R. Parvovirus B19: a review. Dermatol Clin [online] 2002 Apr, 20(2):333-42 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12120446
  5. BLAISE G, NIKKELS AF, PIéRARD GE. [Cutaneous manifestations of parvovirus B19 infection]. Rev Med Liege [online] 2007 Jul-Aug, 62(7-8):492-5 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17853670
  6. KARMOCHKINE M. [Human parvovirus B19 infection. Update]. Rev Med Interne [online] 1995, 16(12):905-12 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8570953
  7. HAREL L, STRAUSSBERG R, RUDICH H, COHEN AH, AMIR J. Raynaud's phenomenon as a manifestation of parvovirus B19 infection: case reports and review of parvovirus B19 rheumatic and vasculitic syndromes. Clin Infect Dis [online] 2000 Mar, 30(3):500-3 [viewed 23 June 2014] Available from: doi:10.1086/313712
  8. NAIDES SJ. Erythema infectiosum (fifth disease) occurrence in Iowa. Am J Public Health [online] 1988 Sep, 78(9):1230-1231 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1349405
  9. ISHII KK, TAKAHASHI Y, KAKU M, SASAKI T. Role of human parvovirus B19 in the pathogenesis of rheumatoid arthritis. Jpn J Infect Dis [online] 1999 Oct, 52(5):201-7 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10680086
  10. KOLIOU MARIA, KARAOLI EVAGGELIA, SOTERIADES ELPIDOFOROS S, PAVLIDES SYLVIE, BASHIARDES STAVROS, CHRISTODOULOU CHRISTINA. Acute hepatitis and myositis associated with Erythema infectiosum by Parvovirus B19 in an adolescent. Array [online] 2014 December [viewed 23 June 2014] Available from: doi:10.1186/1471-2431-14-6
  11. KAUFMANN J, BUCCOLA JM, STEAD W, ROWLEY C, WONG M, BATES CK. Secondary Symptomatic Parvovirus B19 Infection in a Healthy Adult J Gen Intern Med [online] 2007 Jun, 22(6):877-878 [viewed 17 September 2014] Available from: doi:10.1007/s11606-007-0173-9
  12. GLOMERULO KOO TY, KIM GH, PARK H. Clinicopathologic Features of IgA-Dominant Postinfectious Glomerulonephritis Korean J Pathol [online] 2012 Apr, 46(2):105-114 [viewed 17 September 2014] Available from: doi:10.4132/KoreanJPathol.2012.46.2.105

Examination

Fact Explanation
Rash Dermatological findings of erythema infectiosum are the "slapped cheek" appearance on the patient's cheeks, reticular lace like appearance on trunk and limbs, a papular "gloves and-sock" appearance, [3] maculopapular rash, petechiae and purpura. [2] Sometimes there can be associated erythema multiforme or erythema nodosum. [2]
Febrile Temperature may be mildly elevated. [6]
Oral lesions Petechiae, vesicles, pustules and small erosions can be seen in the oral cavity in patients with parvovirus B19 infection. [4]
Pallor Due to the aplastic anaemia. [5]
Features of meningitis/encepahlitis If complicated with meningitis [1]/encephalitis [5], patient's can have neck stiffness, positive Brudzinski and Kernig sign [6] and an altered mental state.
Joint swelling Arthropathy due to parvovirus B19 infection. [5]
Symphysio-fundal height more than period of gestationn This is a clinical finding of hydrops fetalis [5] occurring as a complication of erythema infectiosum in the pregnant population.
References
  1. CANOVIć P, RAVIć-NIKOLIć A. [Acute serous meningitis in a patient with erythema infectiosum]. Vojnosanit Pregl [online] 2006 Jan, 63(1):73-5 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16471253
  2. KATTA R. Parvovirus B19: a review. Dermatol Clin [online] 2002 Apr, 20(2):333-42 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12120446
  3. LEóN-RUIZ L, GUTIéRREZ CABELLO F, GARCíA MELLADO V, JIMéNEZ-ALONSO J. [Papular purpuric "gloves and socks" syndrome secondary to parvovirus B19 infection]. Rev Clin Esp [online] 2001 Apr, 201(4):225-6 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11447916
  4. SKLAVOUNOU-ANDRIKOPOULOU A, IAKOVOU M, PAIKOS S, PAPANIKOLAOU V, LOUKERIS D, VOULGARELIS M. Oral manifestations of papular-purpuric 'gloves and socks' syndrome due to parvovirus B19 infection: the first case presented in Greece and review of the literature. Oral Dis [online] 2004 Mar, 10(2):118-22 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/14996283
  5. BLAISE G, NIKKELS AF, PIéRARD GE. [Cutaneous manifestations of parvovirus B19 infection]. Rev Med Liege [online] 2007 Jul-Aug, 62(7-8):492-5 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17853670
  6. BERNHEIM HA, BLOCK LH, ATKINS E. Fever: pathogenesis, pathophysiology, and purpose. Ann Intern Med [online] 1979 Aug, 91(2):261-70 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/223485

Differential Diagnoses

Fact Explanation
Other viral exanthems eg:-measles, rubella In measles, the rash spreads from forehead to trunk and then to extremities. Koplik Spots are seen in the mouth. Pneumonia, croup, encephalitis and blindness are complications of measles[6]. Rubella also causes exanthem, cervical lymphadenopathy, and mild constitutional symptoms. [7]
Rheumatoid arthritis Rheumatoid arthritis is an inflammation of the synovial joints associated with systemic inflammation. [2] Erythema infectiosum also causes peripheral symmetrical arthritis similar to rheumatoid arthritis. [1] But in rheumatoid arthritis the patient has morning stiffness which improves with physical activity and other systemic manifestations of disease.
Systemic Lupus Erythematosus Presents with polyarthralgia and a butterfly rash of the face, this may be confused with the picture of erythema infectiosum and it's slapped cheek appearance and arthralgia. [3]
Acute viral hepatitis Acute viral hepatitis is a rare complication of parvovirus B19 infection and this may be confused with other viral hepatitis especially when the patient presents with a rash. [4]
Viral conjunctivis Conjunctivitis is associated with erythema infectiosum and this may be confused with other viral conjunctivitis. [5]
References
  1. NAIDES SJ. Rheumatic manifestations of parvovirus B19 infection. Rheum Dis Clin North Am [online] 1998 May, 24(2):375-401 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9606764
  2. SCOTT DL, WOLFE F, HUIZINGA TW. Rheumatoid arthritis. Lancet [online] 2010 Sep 25, 376(9746):1094-108 [viewed 23 June 2014] Available from: doi:10.1016/S0140-6736(10)60826-4
  3. TAKAHASHI T, TAKAYAMA Y, KUNISAKI H, KUSABA N, SUMINO M, YOSHIDA H, SATA M. [Five cases of erythema infectiosum in adults]. Kansenshogaku Zasshi [online] 2001 Jun, 75(6):469-72 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11494563
  4. KOLIOU MARIA, KARAOLI EVAGGELIA, SOTERIADES ELPIDOFOROS S, PAVLIDES SYLVIE, BASHIARDES STAVROS, CHRISTODOULOU CHRISTINA. Acute hepatitis and myositis associated with Erythema infectiosum by Parvovirus B19 in an adolescent. Array [online] 2014 December [viewed 23 June 2014] Available from: doi:10.1186/1471-2431-14-6
  5. SCHARRE JE, VEITH J. Conjunctivitis associated with fifth disease in a child: a case report. J Am Optom Assoc [online] 1996 Dec, 67(12):763-6 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9286318
  6. PERRY RT, HALSEY NA. The clinical significance of measles: a review. J Infect Dis [online] 2004 May 1:S4-16 [viewed 23 June 2014] Available from: doi:10.1086/377712
  7. EDLICH RF, WINTERS KL, LONG WB 3RD, GUBLER KD. Rubella and congenital rubella (German measles). J Long Term Eff Med Implants [online] 2005, 15(3):319-28 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16022642

Investigations - for Diagnosis

Fact Explanation
IgM and IgG antibodies IgM and IgG antibodies to the parvovirus B19 antigen are detected in the serum of patients having erythema infectiosum [1,2].
Anti Nuclear Antibodies (ANA), Rheumatoid Factor (RF) and Compliment levels Done especially if the patient is having features of arthritis to exclude the possibility of Systemic Lupus Erythematosus or Rheumatoid Arthritis. [3]
Full blood count It is important to exclude the possibility of other infections as the patient presents with fever. eg:- bacterial infections causing leucocytosis [4] ,viral infections causing lymphocytosis (elevated lymphocytes) and low platelets in Dengue and other viral infections.
References
  1. CANOVIć P, RAVIć-NIKOLIć A. [Acute serous meningitis in a patient with erythema infectiosum]. Vojnosanit Pregl [online] 2006 Jan, 63(1):73-5 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16471253
  2. HALARIS AE, BELENDIUK KT, FREEDMAN DX. Antidepressant drugs affect dopamine uptake. Biochem Pharmacol [online] 1975 Oct 15, 24(20):1896-7 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19
  3. TANAKA A, SUGAWARA A, SAWAI K, KUWAHARA T. Human parvovirus B19 infection resembling systemic lupus erythematosus. Intern Med [online] 1998 Aug, 37(8):708-10 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9745861
  4. KRAMER MS, TANGE SM, MILLS EL, CIAMPI A, BERNSTEIN ML, DRUMMOND KN. Role of the complete blood count in detecting occult focal bacterial infection in the young febrile child. J Clin Epidemiol [online] 1993 Apr, 46(4):349-57 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8482999

Investigations - Fitness for Management

Fact Explanation
Full blood count As the patients with haematological disorders and immunosuppressive state are vulnerable to aplastic anaemia, their white cell count, red cell count and platelets should be checked for evidence of bone-marrow suppression. [1]
Reticulocyte count A low reticulocyte count is indicative of aplastic anemia. [2]
References
  1. STIBBE KRISTA JM, WILDSCHUT HAJO IJ, LUGTENBURG PIETERNELLA J. Management of aplastic anemia in a woman during pregnancy: a case report. Array [online] 2011 December [viewed 23 June 2014] Available from: doi:10.1186/1752-1947-5-66
  2. YOON HH, HUH SJ, LEE JH, LEE S, KIM SH, KWON HC, KIM HJ. Should we still use Camitta's criteria for severe aplastic anemia? Korean J Hematol [online] 2012 Jun, 47(2):126-130 [viewed 17 September 2014] Available from: doi:10.5045/kjh.2012.47.2.126

Investigations - Followup

Fact Explanation
Parvovirus DNA levels Viral DNA level is checked to assess response to the intravenous immunoglobulin, this level is gradually decreases as the condition improves. [1]
References
  1. ADAMS S. T. M., SCHMIDT K. M., COST K. M., MARSHALL G. S.. Common Variable Immunodeficiency Presenting With Persistent Parvovirus B19 Infection. PEDIATRICS [online] December, 130(6):e1711-e1715 [viewed 23 June 2014] Available from: doi:10.1542/peds.2011-2556

Investigations - Screening/Staging

Fact Explanation
IgM antibodies Detection of IgM antibodies in pregnant mothers is important , as positive mothers can be referred to an ultrasound scan to detect the development of complications such as hydrops fetalis. [1]
Ultrasound scan Ultrasound examination [1] of high risk pregnancies is important in detecting hydrops fetalis.
Cerebro Spinal Fluid examination This is done if there is suspicion of meningitis during the course of erythema infectiosum. There will be an elevation of the number of lymphocytes and mild elevation of level of proteins. [2]
References
  1. FRYDENBERG A, STARR M. Slapped cheek disease. How it affects children and pregnant women. Aust Fam Physician [online] 2003 Aug, 32(8):589-92 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12973864
  2. CANOVIć P, RAVIć-NIKOLIć A. [Acute serous meningitis in a patient with erythema infectiosum]. Vojnosanit Pregl [online] 2006 Jan, 63(1):73-5 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16471253

Management - General Measures

Fact Explanation
Isolation Children can attend school, there is no need for quarantine. [1] Because at the time of the rash, they are no longer contagious.
Attention to high risk groups Patients with hematologic diseases, immunosuppression(organ transplant recipients, long-term steroid usage, acquired immunodeficiency syndrome etc.) and pregnant mothers are considered as high risk groups as they are vulnerable to get complications with erythema infectiosum. [2]
Symptomatic management Patient may be having disabling symptoms such as fever, joint pain, swelling, and itching. Symptomatic treatment is indicated in such situations. [3] This is usually with antipyretics, analgesics, decongestants that should be used where relevant.
Blood products transfusion Patients with aplastic crisis may need red blood cell and platelet transfusions. [3]
References
  1. FRYDENBERG A, STARR M. Slapped cheek disease. How it affects children and pregnant women. Aust Fam Physician [online] 2003 Aug, 32(8):589-92 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12973864
  2. KATTA R. Parvovirus B19: a review. Dermatol Clin [online] 2002 Apr, 20(2):333-42 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12120446
  3. SERVEY JT, REAMY BV, HODGE J. Clinical presentations of parvovirus B19 infection. Am Fam Physician [online] 2007 Feb 1, 75(3):373-6 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17304869

Management - Specific Treatments

Fact Explanation
Self limiting Usually erythema infectiosum is a self limiting disease and requires no specific treatment. [1]
Intravenous Immunoglobulin IV Ig G is given in some situations. [2] It also has an anti-inflammatory property, which is particularly important in the treatment of associated arthritis.
References
  1. SERVEY JT, REAMY BV, HODGE J. Clinical presentations of parvovirus B19 infection. Am Fam Physician [online] 2007 Feb 1, 75(3):373-6 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17304869
  2. ADAMS S. T. M., SCHMIDT K. M., COST K. M., MARSHALL G. S.. Common Variable Immunodeficiency Presenting With Persistent Parvovirus B19 Infection. PEDIATRICS [online] December, 130(6):e1711-e1715 [viewed 23 June 2014] Available from: doi:10.1542/peds.2011-2556