Running head: FIFTH DISEASE 1

Fifth Disease

Megan Schleigh

King University
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FIFTH DISEASE

Fifth Disease

Introduction to Disease

Fifth disease, also known as Erythema Infectiosum, Parvovirus B19, or “slapped cheek

syndrome,” is caused by the Parvovirus B19, an infectious agent that is found worldwide

(O'Grady, 2014). The disease gets its name as it used to be the fifth in the list of historical

classifications of common skin rashes in children (Dutta, 2018). Fifth disease is transmitted by

respiratory droplets most commonly in late winter and early spring (O'Grady, 2014) and by

blood transmission from mother to fetus or exposure to blood or blood products (Burns et al.,

2017). Humans are the only reservoir (Burns et al., 2017).

The peak incidence of the infection is in children ages 5 to 15 years old, although the

disease can develop at any age (O'Grady, 2014). Fifth disease prevalence is relatively common,

as an estimated 40% to 60% of adults test positive for prior infection (O'Grady, 2014).

According to an observational study of children in the United Kingdom who were 6 months to 16

years old who had been immunized for Measles and Rubella revealed that Parvovirus B19 was

the most common identifiable cause of a febrile rash, accounting for 17% of the cases present in

the study (O'Grady, 2014). In this paper, I will discuss signs and symptoms, pathophysiology,

risk factors, diagnosis, treatment, and prevention of disease.

Signs and Symptoms

Presentation of disease symptoms vary widely among individuals. Sometimes, Fifth

disease does not cause any symptoms, as an estimated 20% of individuals that contract the virus

remain subclinical or symptom free (O’Grady, 2014). When symptoms occur, they occur in the

following three stages (Nationwide Children’s Hospital, 2001).

The first stage, also known as the incubation period or prodromal stage, lasts 7 to 14 days
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(Nationwide Children’s Hospital, 2001). This is when the child can spread the disease to others

without knowing (Nationwide Children’s Hospital, 2001). Symptoms may include mild cold

symptoms such as stuffy nose, runny nose, slight fever, body aches, headache and fatigue

(Harvard Health Publishing, 2018). Gastrointestinal symptoms have also been reported which

include nausea, vomiting and diarrhea (Kostolansky & Waymack, 2019). These symptoms pass

after three or four days (Harvard Health Publishing, 2018).

The second stage starts 2 to 3 weeks after exposure (Kostolansky & Waymack, 2019). This

is when the child is no longer contagious (Kostolansky & Waymack, 2019). After flu-like

symptoms resolve a rash develops that is bright red and usually begins on the cheeks which is

why it is called the "slapped cheek" rash (Harvard Health Publishing, 2018). The lesions are

warm, nontender and sometimes pruritic (Hay, Levin, Deterding, & Abzug, 2018). They may be

scattered on the forehead, chin, and post-auricle areas, but the circumoral region, the area around

the mouth, is spared (Hay et al., 2018). The rash is thought to be an immune response, and at the

time the facial rash develops, the patient usually feels well, and the viremia has resolved

(Kostolansky & Waymack, 2019). The facial rash typically lasts 4 to 5 days and may be the only

clinical diagnostic finding in the disease process (Kostolansky & Waymack, 2019).

The third stage occurs after the facial rash disappears and spreads to the rest of the body

and may last 1 to 3 weeks (National Children’s Hospital, 2001). The maculopapular rash during

this stage appears as a lacy, flat rash on the arms, legs, trunk and buttocks (Harvard Health

Publishing, 2018). The rash is typically non-pruritic and may last from several days to several

weeks before it fades (Harvard Health Publishing, 2018). Even after the rash clears, it sometimes

may reappear if the skin is irritated by rubbing, heat, cold, exercise or exposure to sunlight

(Harvard Health Publishing, 2018).

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Adolescents and adults with Fifth disease may not have any symptoms or they may

develop joint pain, stiffness or swelling, most commonly affecting the hands, wrists, feet, ankles

and knees (Harvard Health Publishing, 2018). Women are more affected by joint symptoms than

men and the affected joints are usually symmetric (Harvard Health Publishing, 2018). Joint

involvement is thought to be immune related, as well, and is usually present later in disease

course once the patient is no longer considered infectious (Harvard Health Publishing, 2018).

Joint pain usually resolves within 3 weeks (Harvard Health Publishing, 2018).

Complications

Fifth disease is usually mild for children and adults who are otherwise healthy but for

some people Fifth disease can cause serious health complications (CDC, 2015).

Immunocompromised individuals typically do not show manifestations of rash and joint

symptoms due to the belief that these are immune-mediated, and they would not have an

adequate immune response to this infection for these symptoms to develop (CDC, 2015).

Patients who are immunocompromised may have fever, pallor, tachycardia and symptoms of

heart failure (Burns et al., 2017). Other complications include development of chronic parvovirus

B19 infection which can lead to neutropenia, thrombocytopenia, complete bone marrow

suppression (Kostolansky & Waymack, 2019), myocarditis, and papular-purpuric “gloves and

socks” syndrome (Burns et al., 2017).

Parvovirus B19 infection in pregnant patients can have severe fetal complications

(Kostolansky & Waymack, 2019). These complications include miscarriage, intrauterine death, and

hydrops fetalis (Kostolansky & Waymack, 2019). The risk of fetal loss after acute infection is

approximately 5% (Kostolansky & Waymack, 2019). Mothers in their second trimester of pregnancy

are at greatest risk of developing complications from parvovirus B19, but cases have been reported at
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all points of pregnancy (Kostolansky & Waymack, 2019).

Pathophysiology of Disease Process

Human PV-B19, a member of the family Parvoviridae, is a heat-stable, single-stranded

DNA virus; it is the only parvovirus known to cause disease in humans (Zellman, 2018).

Parvovirus B19 is transmitted most commonly through respiratory droplets into cells in the

respiratory tract but can also be transmitted via blood exposure (Kostolansky & Waymack,

2019). Viremia from parvovirus B19 exposure usually occurs within 5 to 10 days, and the patient

remains contagious approximately 5 days after viremia occurs (Kostolansky & Waymack, 2019).

The development of erythema infectiosum in children is a normal response to infection by

PV-B19 (Zellman, 2018). Acute infection in a host who is immunocompetent leads to a Th-1–

mediated cellular immune response, with the production of specific immunoglobulin M (IgM)

antibodies and subsequent formation of immune complexes (Zellman, 2018). Clinical signs and

symptoms of erythema infectiosum probably result from the deposition of the immune

complexes in the skin and joints of individuals with this condition and not from the circulating

virus (Zellman, 2018). Extremely high viral loads are noted in patients with aplastic crisis, but

low-level persistent polymerase chain reaction positivity in tissues is also common among adults

in a variety of tissues (Zellman, 2018).

Risk Factors

Risk factors for developing Fifth disease include winter and spring seasons, although the

virus can be contracted at any time; and areas of high contagiousness, such as preschool and

elementary school (Mersch, 2018). Fifth disease is common in children 5 to 15 years old (March

of Dimes, 2018). It is estimated that about half of people get Fifth disease sometime during

childhood or their teens (American Academy of Family Physicians, 2017). People with young
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children and those who work with children, such as childcare providers and teachers, are most

likely to get infected with Fifth disease (March of Dimes, 2018). Since the most contagious time

period is when the child has no overt symptoms, exposure to a healthy child is a common

experience (Mersch, 2018). If a child in a home has Fifth disease, there is a 50% chance that

another family member who has not had the infection before will get it (March of Dimes, 2018).

Those with Fifth disease who are immunocompromised are potentially more at risk for the

development of complications than compared to immunocompetent individuals (Mersch, 2018).

Once an individual has contracted Fifth disease, they are considered immune for life and cannot

get infected again (March of Dimes, 2018).

Diagnosis of Disease (Screening and Testing)

Diagnosis of parvovirus B19 infection is usually not warranted due to the self-limiting

progression of the disease and typically mild symptoms (Kostolansky & Waymack, 2019).

Differential diagnoses include rubella, enterovirus disease, lupus, atypical measles and drug

rashes (Burns et al., 2017). Laboratory testing is not generally indicated because the diagnosis is

usually not difficult to diagnose and can be made clinically (Burns et al., 2017) by the

appearance of the “slapped cheek” rash on the patient’s face (CDC, 2015). However, laboratory

testing can be useful in patients with aplastic crisis diagnosis to confirm and help support

causation from acute parvovirus B19 detection (Kostolansky & Waymack, 2019). Serum B19-

specific IgM antibody confirms the presence of infection and persists for 6 to 8 weeks (Burns et

al., 2017). Anti-B19 IgG confirms past infection (Burns et al., 2017). For immunocompromised

individuals, PCR assay is the method of choice (Burns et al., 2017). Testing for IgG antibodies

can be common in prenatal testing for women to look for immunity status to parvovirus B19 to

access the risk of potential congenital disabilities (Kostolansky & Waymack, 2019). Standard
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cultures are not useful (Burns et al., 2017).

Treatment of Disease

Treatment of Fifth disease usually involves symptom control and supportive management

as the disease process is typically self-limiting (Kostolansky & Waymack, 2019). Use of

acetaminophen and/or NSAIDs for fever control, arthralgias, and headache is commonly used

(Kostolansky & Waymack, 2019). There is currently no antiviral treatment (Burns et al., 2017)

that will help shorten the course of the disease (Rivers & Yu, n. d.). In uncomplicated cases,

most doctors advise people with Fifth disease to wait out the symptoms until they resolve on

their own (Rivers & Yu, n. d.).

In complicated cases, such as those with hemolytic anemia or immunosuppression, should

be considered for transfusion therapy (Burns et al., 2017). IVIG offers some help for those with

immunocompromised conditions (Burns et al., 2017). If an aplastic crisis is found on workup,

then serial hemoglobin/hematocrit testing should be performed with red blood cell transfusions,

as needed, throughout the viral infection (Kostolansky & Waymack, 2019). If a mother is found

to have acute parvovirus B19 infection early in pregnancy, she will need close follow-up with

her obstetrician for serial ultrasounds and to monitor for possible fetal complications

(Kostolansky & Waymack, 2019).

Prevention of Disease

There is currently no vaccine or medicine that can prevent parvovirus B19 infection (CDC,

2015). However, one can reduce their chance of being infected or infecting others by simple

practices. The CDC (2015) recommends the following to help prevent the spread of the virus:

 washing your hands often with soap and water

 covering your mouth and nose when you cough or sneeze

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 not touching your eyes, nose, or mouth

 avoiding close contact with people who are sick

 not sharing food or drinks with other people

 staying home when you are sick

An individual that has Fifth disease is most contagious when it seems like they have “just a

fever and/or cold” before the rash or joint pain/swelling occurs (CDC, 2015). Once the rash

appears, the individual probably is not considered contagious (CDC, 2015) and no longer need to

be isolated and can return to school or work (Mayo Clinic, n. d.). However, people with Fifth

disease who have weakened immune systems may be contagious for a longer amount of time

(CDC, 2015). Once someone has become infected with parvovirus, they acquire lifelong

immunity and cannot get sick if exposed to the virus again (Nationwide Children’s Hospital,

2001).

Summary

In summary, Fifth disease is caused by the Parvovirus B19 and is considered a common

disease in early childhood (O'Grady, 2014) and is transmitted via respiratory droplets and blood.

Although the disease occurs most frequently in children, it can develop at any age (O'Grady,

2014). It is estimated that an estimated 40% to 60% of adults test positive for prior infection

(O'Grady, 2014).

Presentation of disease symptoms vary widely among individuals. For individuals that

develop symptoms, symptoms usually occur in three stages. The three stages include flu-like

symptoms, a ''slapped cheek" rash, and finally a maculopapular rash that spreads to the rest of the

body (Harvard Health Publishing, 2018). Once the rash on the face appears, the individual is
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probably not considered contagious (CDC, 2015). Adolescents and adults with Fifth disease may

not have any symptoms or they may develop joint pain, stiffness or swelling (Harvard Health

Publishing, 2018). Fifth disease is usually mild for children and adults who are otherwise

healthy but for some people Fifth disease can cause serious health complications especially for

those who are immunocompromised or pregnant (CDC, 2015).

Diagnosis of parvovirus B19 infection is usually not warranted due to the self-limiting

progression of the disease and typically mild symptoms (Kostolansky & Waymack, 2019).

Symptom control and supportive management, such as use of Acetaminophen and/or NSAIDs,

are the basis for treatment of Fifth disease (Kostolansky & Waymack, 2019). There is currently

no preventative medication, vaccine, or medications to help shorten the course of the disease

(CDC, 2015). However, the CDC (2015) recommends simple measures to help prevent the

spread of the virus such as washing hands and avoiding contact with people who are sick.

Individuals that have been become infected with the virus acquire lifelong immunity from

contracting the virus again (Nationwide Children’s Hospital, 2001).

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References

American Academy of Family Physicians. (2017). Fifth disease. Retrieved from https://familydo

ctor.org/condition/fifth-disease/

Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B. Blosser, C. G., & Garzon, D. L. (2017).

Pediatric primary care. (6th ed.). St. Louis, MO: Elsevier.

Centers for Disease Control and Prevention [CDC]. (2015). Fifth disease. Retrieved from https://

www.cdc.gov/parvovirusb19/fifth-disease.html

Dutta, S. S. (2018). Fifth disease complications and prevention. Retrieved from https://www.ne

ws-medical.net/health/Fifth-Disease-Complications-and-Prevention.aspx

Harvard Health Publishing. (2018). Fifth disease (erythema infectiosum). Retrieved from https://

www.health.harvard.edu/a_to_z/fifth-disease-erythema-infectiosum-a-to-z

Hay, W. W., Levin, M. J., Deterding, R. R., & Abzug, M. J. (2018). Current diagnosis & treatm

ent. (24th ed.). New York, NY: McGraw-Hill Education.

Kostolansky, S. & Waymack, J. R. (2019). Erythema infectiosum (fifth disease). Retrieved from

https://www.ncbi.nlm.nih.gov/books/NBK513309/

Mayo Clinic. (n. d.). Parvo virus. Retrieved from https://www.mayoclinic.org/diseases-condition

s/parvovirus-infection/symptoms-causes/syc-20376085

Mersch, J. (2018). Fifth disease. M. C. Stöppler (Ed.). Retrieved from https://www.emedicinehe

alth.com/fifth_disease/article_em.htm#when_should_someone_seek_medical_care_for_

fifth_disease

Nationwide Children’s Hospital. (2001). Fifth disease (erythema infectiosum). Retrieved from

https://www.nationwidechildrens.org/conditions/fifth-disease

O'Grady, J. S. (2014). Fifth and sixth diseases: More than a fever and a rash. The Journal of Fam
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ily Practice, 63(10), 1-5. Retrieved from https://www.mdedge.com/familymedicine/articl

e/87594/pediatrics/fifth-and-sixth-diseases-more-fever-and-rash

Rivers, A., & Yu, W. (n. d). Everything you need to know about fifth disease. Retrieved from htt

ps://www.healthline.com/health/fifth-disease

Zellman, G. L. (2018). Erythema infectiosum. D. M. Elston (Ed.). Retrieved from https://emedic

ine.medscape.com/article/1132078-overview#a3