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Walid Abuhammour, MD; Nahed Abdel-Haq, MD; Basim Asmar, MD
From the Department of Pediatrics, Wayne State University School of Medicine, Division of Infectious Diseases, Children's Hospital of Michigan, Detroit.

Arch Pediatr Adolesc Med. 1999;153:87-88.

OVER 5 days, a previously healthy 13-year-old girl developed fever, bilateral conjunctival injection, difficulty swallowing, swollen knees, and a petechial rash. Physical examination showed her lips to be swollen and red, her throat red with a pharyngeal ulcer, and small vesicular lesions at the base of the tongue and on the buccal mucosa of the left cheek (Figure 1). Her conjunctivae were injected. Both knee joints were swollen and mildly tender to motion and palpation. A discrete petechial rash was present on the legs below the knees, including the dorsum and plantar surfaces of the feet and on the forearms, and palms of both hands (Figure 2 and Figure 3). The fingers of both hands were swollen.

Figure 1.

Figure 2.

Figure 3.

The white blood cell count was 2.4 x10⁹/L (reference range, 4.5-11.0 x10⁹/L) and differential cell count of 0.69 polymorphonuclear cells, 0.15 band forms, 0.11 lymphocytes, and 0.5 monocytes. The hemoglobin was 132 g/L (reference range, 120-150 g/L), and a platelet count of 82 x10⁹/L (reference range, 150-450 x10⁹/L).

Denouement and Discussion: Petechial Eruption With Parvovirus B19 Infection

Figure 1. The lips are swollen and 2 shallow ulcers are visible on the undersurface of the tongue.

Figure 2. A discrete petechial rash is present on the feet.

Figure 3. A discrete petechial rash is present on the hand and the fingers are swollen.

Parvovirus B19, discovered in 1974, is a small, nonenveloped, single-stranded DNA virus, belonging to the family Parvoviridae.^1-2 Infection with Parvovirus B19 is common. The prevalence of IgG antibodies to the virus ranges from 2% to 15% in children from 1 to 5 years of age and from 30% to 60% in adults.^3-4 Clinical infection with this virus is most common in school-aged children. The mode of spread is believed to be by respiratory droplets. Secondary spread among susceptible household members occurs in about 50% of contacts.³

CLINICAL PRESENTATIONS
In the immunologically normal host, Parvovirus B19 infection may be asymptomatic, may result in erythema infectiosum (fifth disease), or may induce arthritis.^5-6 Erythema infectiosum, characterized by the "slapped cheek" appearance and lacey erythema of the proximal extremities, is the most common clinical manifestation of Parvovirus B19 infection and occurs most frequently in school-aged children. Once the rash appears, the children are no longer capable of transmitting the disease.

Petechial rashes, with or without thrombocytopenia and vesiculobullous lesions, have also been associated with Parvovirus B19 infections.^7-8 More recently, a distinctive exanthem known as the papular-purpuric "gloves and socks" or the petechial gloves and socks syndrome has been described in older children and adults, many of whom have demonstrated evidence of Parvovirus B19 infection.^9-11 The clinical picture of this illness is characterized by pruritic edema and erythema of the hands and feet in a gloves and socks distribution, oral lesions, and fever, followed by the rapid development of petechiae on the hands and feet.

Parvovirus B19 may cause an aplastic crisis in patients with chronic hemolytic anemias. Although megakaryocytes and myeloid cells are not infected, neutropenia, thrombocytopenia, or both are commonly found in these patients.^12-13 In patients with immunodeficiency, congenital or acquired, Parvovirus B19 infection may become chronic, resulting in persistent viremia and bone marrow failure. Most of these immunodeficient patients do not experience the rash, fever, or polyarthropathy frequently associated with this infection.¹⁴

Parvovirus B19 infection has also been implicated as a possible cause of idiopathic thrombocytopenic purpura. In a series of 35 previously healthy children with classic idiopathic thrombocytopenic purpura, almost half had evidence of Parvovirus B19 DNA in peripheral blood or bone marrow, while none of 14 control patients had polymerase chain reaction or anti–B19 IgM antibodies.¹⁵ Parvovirus B19 infection also accounts for as much as one fourth of the cases of nonimmune fetal hydrops by causing red blood cell aplasia.¹⁶

In addition, Parvovirus B19 has been demonstrated to be a cause of arthritis, chronic encephalitis, and aseptic meningitis among otherwise normal children.⁶

DIAGNOSIS
In the healthy host, detection of IgM antibodies to Parvovirus B19 denotes a recent infection. Both IgM and IgG antibodies are present soon after the onset of illness and reach peak titers in the first 30 days. IgG antibodies persist for years, but IgM antibody levels begin to decline 30 to 60 days after the onset of the illness. Hybridization techniques or polymerase chain reaction may also be useful in detecting Parvovirus B19 infection. These techniques have been used to detect viral DNA in clinical samples of serum, urine, respiratory secretions, and body tissues.

TREATMENT
Antiviral therapy for this infection is unavailable. For most patients, supportive care only is indicated. Intravenous immunoglobulin therapy may be effective in treating Parvovirus B19 infection in immunodeficient patients.¹⁴

AUTHOR INFORMATION
Accepted for publication September 5, 1997.

Reprints: Basim Asmar, MD, Children's Hospital of Michigan, 3901 Beaubien Blvd, Detroit, MI 48201-2196.

REFERENCES
1. Cossart YE, Field AM, Cant B, Widdows D. Parvovirus-like particles in human sera. Lancet. 1975;1:72-73. ISI | PUBMED 2. Brown KE, Young NS, Liu JM. Molecular, cellular and clinical aspects of Parvovirus B19 infection. Crit Rev Oncol Hematol. 1994;16:1-31. ISI | PUBMED 3. Anderson LJ. Role of Parvovirus B19 in human disease. Pediatr Infect Dis J. 1987;6:711-718. ISI | PUBMED 4. Koch WC, Adler SP. Human Parvovirus B19 infections in women of childbearing age and within families. Pediatr Infect Dis J. 1989;8:83-87. ISI | PUBMED 5. Bell LM, Naides SJ, Stoffman P, Hodinka RL, Plotkin SA. Human Parvovirus B19 infection among hospital staff members after contact with infected patients. N Engl J Med. 1989;321:485-491. ABSTRACT 6. Nocton JJ, Miller LC, Tucker LB, Schaller JG. Human Parvovirus B19-associated arthritis in children. J Pediatr. 1993;122:186-190. ISI | PUBMED 7. Hogan PA. Viral exanthems in childhood. Aust J Dermatol. 1996;37(suppl):514-516. 8. Lefrere JJ, Courouce AM, Kaplan C. Parvovirus and idiopathic thrombocytopenic purpura [letter]. Lancet. 1989;1:279. 9. Harms M, Feldman R, Saurat JH. Papular-purpuric "gloves and socks" syndrome. J Am Acad Dermatol. 1990;23:850-854. ISI | PUBMED 10. Halasz CLG, Cormier D, Den M. Petechial glove and sock syndrome caused by Parvovirus B19. J Am Acad Dermatol. 1992;27:835-838. ISI | PUBMED 11. Stone MS, Murph JR. Papular-purpuric gloves and socks syndrome: a characteristic viral exanthem. Pediatrics. 1993;92:864-865. FREE FULL TEXT 12. Mustafa MM, McClain KL. Diverse hematologic effects of Parvovirus B19 infection. Pediatr Clin North Am. 1996;43:809-821. FULL TEXT | ISI | PUBMED 13. Muir K, Todd WT, Watson WH, Fitzsimmons E. Viral-associated haemophagocytosis with Parvovirus-B19–related pancytopenia. Lancet. 1992;339:1139-1140. FULL TEXT | ISI | PUBMED 14. Koch WC, Massey G, Russell CE, Adler SP. Manifestations and treatment of human Parvovirus B19 infection in immunocompromised patients. J Pediatr. 1990;116:355-359. FULL TEXT | ISI | PUBMED 15. Murray JC, Kelley PK, Hogrefe WR, McClain KL. Childhood idiopathic thrombocytopenic purpura: association with human Parvovirus B19 infection. Am J Pediatr Hematol Oncol. 1994;16:314-319. ISI | PUBMED 16. Anand A, Gray ES, Brown T, Clewley JP, Cohen BJ. Human Parvovirus infection in pregnancy and hydrops fetalis. N Engl J Med. 1987;316:183-186. ABSTRACT

SECTION EDITOR: WALTER W. TUNNESSEN, JR, MD

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