About Parvovirus B19

AT A GLANCE

• Parvovirus B19 infection is usually mild in people who are otherwise healthy.
• Common symptoms include "slapped cheek" rash in children, and joint pains in adults.
• Complications can occur among people with underlying blood disorders or weakened immune system.
• Infection early during pregnancy can cause a slight increase in the risk of a miscarriage.

Overview

Parvovirus B19 infection usually causes no symptoms or mild illness, such as flu-like symptoms, rashes and joint pains. In individuals with blood disorders or a weakened immune system, infection can cause a low blood count. Infection during pregnancy can sometimes lead to additional complications.

Some people who get infected with this virus will have no symptoms.

When symptoms of parvovirus B19 infection occur, they are usually mild and may include the following:

• Fever
• Headache
• Cough
• Sore throat
• Rashes
• Joint pain

Rashes

The clinical presentation most often associated with parvovirus B19 infection is a red rash on the face, also called a "slapped cheek" rash. This is also known as Fifth Disease (or Erythema Infectiosum). This rash typically appears a few days after the fever or flu-like symptoms. It is more common in children than adults.

Parvovirus B19 infection can also cause a general rash on the chest, back, buttocks, or arms and legs. The rash may be itchy. It usually goes away in 7 to 10 days but can come and go for several weeks. As it starts to go away, it may look lacy.

Joint Pain

Infection with parvovirus B19 can lead to pain and swelling in the joints, called polyarthopathy syndrome. This is more common in adults and children and is most common in women.

Adults may experience joint pain without other symptoms. Joints are affected on both sides, usually in the hands, feet and knees. The joint pain usually lasts 1 to 3 weeks but can last for months or longer. It usually goes away without any long-term problems.

Parvovirus B19 infection is usually mild for children and adults who are otherwise healthy. However, for some people, it can cause serious health complications affecting the nerves, joints, or blood system.

Parvovirus B19 has been shown to cause a severe drop in blood count (anemia) in some patients with certain blood disorders or with a weakened immune system.

You may be at increased risk for complications from a parvovirus B19 infection if you have one or more of these health conditions:

• Leukemia or other cancers
• Organ transplant
• HIV infection
• Blood disorders such as sickle cell disease and thalassemia

Preventing Parvovirus B19

KEY POINTS

• There is no vaccine or treatment that can prevent parvovirus B19 infection.
• Follow general respiratory precautions to prevent spread of parvovirus B19.
• See your healthcare provider if you have complications from a parvovirus B19 infection or are infected while pregnant.

How it spreads

Parvovirus B19 can spread from person to person through:

• Respiratory particles
• Blood or blood products
• During pregnancy (from mother to baby)

Facts about Parvovirus B19 Infection‎

Parvovirus B19 Only Infects People

Since parvovirus B19 only infects people, a person cannot get the virus from a dog or cat. Also, dogs and cats cannot get parvovirus B19 from an infected person. Dogs and cats can get infected with other parvoviruses that do not infect people.

In special circumstances, your healthcare provider may test your blood for parvovirus antibodies. The test will determine if you are susceptible or possibly immune to parvovirus B19 infection or if you were recently infected.

Talk to your healthcare provider if you have any questions about whether you should get tested.

Parvovirus B19 infections are usually mild and will go away on their own. Children and adults who are otherwise healthy usually recover completely.

Treatment usually involves relieving symptoms, such as fever, itching, and joint pain and swelling. For persons who develop a low blood count, treatment may include supportive care, blood products, and other specialized therapies.

See your healthcare provider if:

• You have complications from a parvovirus B19 infection, or
• You are infected while pregnant.

Parvovirus B19 in Pregnancy

KEY POINTS

• Getting a parvovirus B19 infection will usually not impact your pregnancy or your baby.
• However, if infected, the virus could spread to your developing baby.
• Infection early in the pregnancy can lead to a small increase in the risk of a miscarriage, or other complications.
• Contact your healthcare provider if you show signs of parvovirus B19 infection or have been exposed to someone with this infection.

Overview

Most adults have already had a parvovirus B19 infection and have immune protection. If you are one of these protected adults, you and your baby are usually protected from the virus.

Even if you are not immune, not everyone who is exposed becomes infected. Most likely, you will have a mild illness if you get a parvovirus B19 infection. Also, this will not usually impact your pregnancy or have long-term impacts on your baby.

If you get infected with parvovirus B19 during pregnancy, it is possible to spread the virus to your developing baby. Infection during the first half of pregnancy may lead to severe anemia in your baby. It may result in miscarriage in some cases.

Reducing risk

All healthcare providers and patients should follow recommended infection control practices to prevent the spread of parvovirus B19 and follow core prevention strategies. Pregnant people may choose to continue going to their workplace.

Healthcare providers who are pregnant should know about the potential risks and discuss this with their doctor and occupational health provider.

Testing

A blood test for parvovirus B19 antibodies may indicate whether you:

• Have protection (immunity) against parvovirus B19.
• Have had a recent or past infection.

If you are pregnant, contact your obstetrician or healthcare provider if:‎

You show signs of parvovirus B19 infection, such as new rash or joint pains, or if you have been exposed to someone with a parvovirus B19 infection.

Monitoring parvovirus B19 infection during pregnancy

If you have a parvovirus B19 infection during pregnancy, your healthcare provider may recommend additional prenatal visits, blood tests, and ultrasound scans.

Following discussions with your doctor, certain specialized procedures might be considered to lower the risk of miscarriage.

Introduction

Parvovirus B19 is a non-enveloped, icosahedral virus containing a single-stranded, linear DNA genome. This virus only infects humans. The virus is known to cause fifth disease, also known as erythema infectiosum or slapped cheek syndrome, which occurs mostly in young children but can occur in adults. It can also cause an aplastic crisis in those with certain anemias, hydrops fetalis in pregnant women, polyarthropathy, and papular-purpuric gloves and socks syndrome (PPGSS) in young adults. Transmission of the virus occurs through respiratory secretions and blood products. If a woman becomes pregnant and gets infected, the virus can be passed to her baby.

Etiology

Parvovirus B19 is a non-enveloped, icosahedral virus that contains single-stranded linear DNA. It only infects humans, so it cannot be caught from animals.

Epidemiology

Parvovirus B19 infection occurs worldwide and is most common in school-aged children. The prevalence of parvovirus B19 in developed countries in children younger than five years is 2% to 10%, 40% to 60% in adults older than 20 years, and 85% or more in people 70 years and older. Infections with parvovirus B19 tend to occur more often in the late winter, spring, and early summer. Mini-outbreaks of parvovirus B19 infection occur about every three to four years.

Pathophysiology

Parvovirus B19 is a non-enveloped virus that binds to host cell receptors in the respiratory tract and enters the cell. It then translocates its genome to the host nucleus, whereby DNA replication, RNA transcription, and assembly of the virus occurs. Lastly, the cells lyse and release the mature virions. Viremia occurs and creates the prodrome of symptoms that patients experience. The IgM antibody appears when viremia resolves, which is approximately eight to 10 days post-inoculation. During the viremic period, reticulocytopenia occurs for seven to 10 days. One week after the appearance of the IgM antibody, the IgG antibody appears and coincides with the appearance of the rash and arthralgia. Parvovirus is tropic to bone marrow and replicates in erythroid precursors. The P antigen is the cellular receptor for parvovirus B19 that causes erythema infectiosum in children.

Histopathology

Histopathology is generally not useful in parvovirus B19 infection. However, PPGSS shows a lymphocytic dermal infiltrate with extravasation of erythrocytes.

History and Physical

Erythema Infectiosum

The prodrome of symptoms begins during viremia, where patients experience a headache, myalgias, and fever. The exanthem develops one to one and one-half weeks later. It is important to know that the patient is not contagious once the eruption occurs. At this time, the patient will have a “slapped cheek” appearance, described as erythema of the cheeks, sparing the central face. This finding is the most recognizable for this disease. Adults may not have the facial rash with this infection. Later, a maculopapular eruption occurs that looks “lacy” and reticular and favors the extremities but occurs on the trunk to a lesser extent. The eruption can last anywhere from one to three weeks. The rash can worsen when exposed to heat or sunlight. Arthritis of the small joints may occur, namely the hands, feet, and knees; however, this is more common in adults. It is especially common in women and is rare in children, where it occurs in only 10%.

Arthritis may occur without the skin findings, and it usually lasts one to three weeks.

Aplastic Crisis

This may occur in those with preexisting conditions such as decreased red cell production (iron deficiency and thalassemias) or increased red cell destruction (sickle cell anemia, hereditary spherocytosis, pyruvate kinase deficiency, glucose-6-phosphate dehydrogenase deficiency), as well as recipients of allogeneic hematopoietic stem cell or solid organ transplants and patients with HIV infection.

Fetal B19 Infection

Vertical transmission of parvovirus B19 can occur from the mother to the fetus. Transmission is the highest before 20 weeks gestation. The virus blocks fetal erythropoiesis, leading to profound anemia, stillbirth, hydrops, and/or fetal death. Hydrops is defined as the abnormal accumulation of fluid in two or more fetal compartments, including ascites, pleural effusion, pericardial effusion, and skin edema. Most fetal losses occur in the second trimester. However, the overall risk of fetal loss while pregnant is 2% to 6%. The virus is not usually tested for in preconception or antenatal screenings. Most babies born to mothers with the infection are born asymptomatic and full-term.

Papular Purpuric Gloves and Socks Syndrome

This condition usually occurs in young adults but can occur at any age. On exam, one will find petechiae and purpura with a sharp demarcation at the wrists and ankles. There also will be symmetric edema and erythema of the palms and soles that may extend onto the dorsal surfaces, and patients may complain of burning or pruritus. Some sources have documented cases involving intertriginous areas of the body as well. Unlike erythema infectiosum, patients are contagious when they have a rash. Erosions and petechiae may occur in the mouth involving the palate, pharynx, and tongue.

Evaluation

The preferred method to test for infection is by checking a serum anti-B19 IgM antibody. If it is positive, it indicates infection within the previous two to four months. The IgG antibody will be positive after one week. PCR testing from the serum or tissue can also be used.

Treatment / Management

Treatment is typically symptomatic. Children with erythema infectiosum usually feel well during the infection and do not require treatment. If arthropathy is present, NSAIDs can be used. Red blood cell transfusions can be given to patients in aplastic crisis. Mothers with confirmed infection in the one and two weeks of pregnancy should be monitored closely with serial ultrasounds. If needed, transfusions can be given to the fetus while in utero.

Differential Diagnosis

• The differential diagnosis of erythema infectiosum includes scarlet fever, enteroviral infection, rubella, Still disease, erysipelas of the face, contact dermatitis, Kawasaki disease, roseola infantum, measles, and drug eruption.
• The differential diagnosis of PPGSS includes meningococcal infection, erythema multiforme, Henoch-Schonlein purpura, and chemotherapy-related painful acral erythema.

Prognosis

Erythema infectiosum is usually mild for those that are healthy. However, it can cause serious complications in immunocompromised patients. In some people. parvovirus B19 can cause chronic anemia requiring treatment. After a person becomes infected with erythema infectiosum, immunity is obtained that protects one from infection in the future. Most of the time PPGSS resolves on its own without any sequelae.

Pearls and Other Issues

• Patients with the "slapped cheek" appearance in erythema infectiosum are not contagious at that time.
• Patients with the rash of papular-purpuric gloves and socks syndrome are contagious at that time.

Enhancing Healthcare Team Outcomes

Parvovirus infections are often managed by the pediatrician, primary care provider, or nurse practitioner. In most cases, the treatment is typically symptomatic. Children with erythema infectiosum usually feel well during the infection and do not require treatment. If arthropathy is present, NSAIDs can be used. Red blood cell transfusions can be given to patients in aplastic crisis. Mothers with confirmed infection in the one and two weeks of pregnancy should be monitored closely with serial ultrasounds. If needed, transfusions can be given to the fetus while in utero. After a person becomes infected with erythema infectiosum, immunity protects one from infection in the future. Most of the time, PPGSS resolves on its own without any sequelae