The clinical signs of erythema infectiosum in children start to appear soon after the incubation period and include low grade fever, headache and flu like symptoms similar to those of rhinitis. Less common symptoms include sore throat, diarrhea, swollen glands and reddish cornea. The disease is self-limited and the illness period is followed by the emerging of rash on the facial skin. The specific slapped cheek appearance of the rash is ensued by the rash spreading to trunk, limbs and the whole body. However, palms and soles are usually not affected. The rash manifests as a lacy net like appearance known as erythema exanthum. Pruritis is usually absent although some children may complain about itchiness due to the rash. 

In adults, a specific manifestation of the disease is acute polyarthopathy. It is more common in women and typically persists for few days up to several months.
During the prodromal phase (a week after exposure to PV-B19), other symptoms may appear in adults as well as in children such as coryza, abdominal pain, fever, pruritis and sore throat. 

• Fever

  However, some children have a low fever and feel mildly ill with a headache and a runny nose for a few days. [merckmanuals.com]

  It lacks the sandpaper texture that tends to characterize the rash of scarlet fever, a form of streptococcal infection. Nor did Johnny have the red throat that often accompanies scarlet fever, nor was he as sick as scarlet fever victims usually are. [nytimes.com]

• Anemia

  Thus, patients with sickle cell anemia, thalassemia, acute hemorrhage and iron deficiency anemia are at risk. 21, 22 Typically, these patients have a viral prodrome followed by anemia, often with hemoglobin concentrations falling below 5.0 g per dL (50 [aafp.org]

  Parvovirus B19 infection can trigger an acute cessation of red blood cell production, causing transient aplastic crisis, chronic red cell aplasia, hydrops fetalis, or congenital anemia. [ncbi.nlm.nih.gov]

  Aplastic anemia The association of human PV-B19 with aplastic anemia is thought to be due to the affinity and cytotoxicity of the virus for erythroid progenitor cells. [emedicine.com]

• Malaise

  Typical initial manifestations are nonspecific flu-like symptoms (eg, low-grade fever, slight malaise). [merckmanuals.com]

  The pediatrician rejected measles because the cough, high fever and malaise that usually accompany that viral illness were absent. Besides, Johnny had been immunized. [nytimes.com]

• Fatigue

  Fatigue : fatigue as a concept is extremely hard to define, since everybody has their own idea of what being tired means. Influenza (flu) : Are there different types of influenza? Last updated 23.09.2014 [netdoctor.co.uk]

  Symptoms include low-grade fever, fatigue, a "slapped cheeks rash ," and a rash over the whole body. [medicinenet.com]

  Fatigue Fatigue is extreme tiredness and lack of energy. Immune The immune system is the body's defence system, which helps protect it from disease, bacteria and viruses. [hse.ie]

• Infectious Mononucleosis

  The physician will also exclude other potential causes for the symptoms and rash, including rubella, infectious mononucleosis, bacterial infections such as Lyme disease, allergic reactions, and lupus. [encyclopedia.com]

  LAMELLA, A THIN LAYER) IMPETIGO IMPETIGO OF THE NEWBORN (IMPETIGO NEONATORUM) INCONTINENTIA PIGMENTI INFECTIOUS MONONUCLEOSIS INGROWN TOENAIL IRITIS, TRAUMATIC J JEALOUSY– online-only JUGULAR VEIN DISTENTION – online-only JUVENILE DERMATOMYOSITIS JUVENILE [euro-libris.ro]

  Acute erythroblastopenia in sickle-cell anemia and infectious mononucleosis. AMA Am J Dis Child. 1951 Sep; 82 (3):310–322. [ PubMed ] Serjeant GR, Topley JM, Mason K, Serjeant BE, Pattison JR, Jones SE, Mohamed R. [ncbi.nlm.nih.gov]

• Diarrhea

  Less common symptoms of fifth disease include: Diarrhea Swollen glands Red eyes Sore throat Swollen joints (more common in older children and adults) Fifth Disease Treatments Because fifth disease is a virus, it cannot be treated with antibiotics. [boystownpediatrics.org]

  Symptoms may also include an upset stomach (nausea and diarrhea). It starts as a very red rash on the cheeks that looks like the face has been slapped. [caringforkids.cps.ca]

  Tumors 479 Wilms Tumor 481 Neuroblastoma 482 Retinoblastoma 484 Histiocytic Proliferative Diseases 485 Genitourinary System 486 Enuresis 487 Glomerulonephritis 490 Nephrotic Syndrome 495 Hypertension 518 Gastrointestinal System 523 Chronic Nonspecific Diarrhea [books.google.com]

  Sometimes fifth disease also can cause swollen glands, red eyes, sore throat, diarrhea, and rarely, rashes that look like blisters or bruises. [kidshealth.org]

• Arthralgia

  Leg pain and arthralgia occurred in five of the children. [ncbi.nlm.nih.gov]

  Approximately 8 percent of children infected with the virus have arthralgia. However, arthralgia is more common in adolescents and adults with parvovirus B19 infection, affecting up to 60 percent of these persons. [aafp.org]

  Adults, more than children, may report arthritis and arthralgias. Most cases do not require specific treatment beyond symptomatic therapy and reassurance. [bestpractice.bmj.com]

  The illness usually starts with fever and non-specific influenza-like symptoms followed by rash, fever and rheumatic symptoms such as arthralgia or arthritis [ 2 ]. [bmcpediatr.biomedcentral.com]

• Symmetrical Arthritis

  About 80% of adults with fifth disease have joint aches and pains ( arthritis ) which may become long-term with stiffness in the morning, redness and swelling of the same joints on both sides of the body (a "symmetrical" arthritis), most commonly involving [medicinenet.com]

  arthritis which may become chronic with stiffness in the morning, redness and swelling; B19 can infect the fetus before birth. [medical-dictionary.thefreedictionary.com]

  Patients develop acute symmetric arthritis affecting the small joints of the hands and feet, typically lasting for 1-3 weeks. In a small number, the arthritis may be prolonged, lasting for months. [emedicine.com]

• Hydrops Fetalis

  Hydrops fetalis due to parvovirus infection is treated by intrauterine transfusion. Self-skin examination New smartphone apps to check your skin Learn more (Sponsored content) Related information References Kishore J. [dermnetnz.org]

  In pregnant women, however, it may be associated with fetal death and nonimmune hydrops fetalis. [ncbi.nlm.nih.gov]

  Hydrops fetalis and fetal death are complications of intrauterine parvovirus B19 infection. [aafp.org]

  Fetal complications include hydrops fetalis and intrauterine fetal demise. [bestpractice.bmj.com]

• Pruritus

  Pruritus was detected in 10.26% of children. The most constant clinical sign was reticular exanthema on the limbs, present in 100% of cases, jollowed by 89.74% of cheek exanthema, while limb and trunk exanthema was present in 7.68% of children. [ncbi.nlm.nih.gov]

  Pruritus that is sometimes severe can occur with or without a rash. It has been suggested that if pruritus is a complaint in a patient with acute-onset arthritis, parvovirus should be considered as a possible cause. [dermaamin.com]

  Pruritus may be present. Color Atlas of Pediatric Dermatology Samuel Weinberg, Neil S. Prose, Leonard Kristal Copyright 2008, 1998, 1990, 1975, by the McGraw-Hill Companies, Inc. All rights reserved. [webmd.com]

• Skin Rash

  […] erythema [ er″ĭ-the´mah ] redness of the skin caused by congestion of the capillaries in the lower layers of the skin. [medical-dictionary.thefreedictionary.com]

  This disease, also called erythema infectiosum, got its name because it was fifth in a list of historical classifications of common skin rash illnesses in children. [cdc.gov]

  The disease is self-limited and the illness period is followed by the emerging of rash on the facial skin. The specific slapped cheek appearance of the rash is ensued by the rash spreading to trunk, limbs and the whole body. [symptoma.com]

• Eczema

  […] online-only DERMATITIS ARTEFACTA (see NEUROTIC EXCORIATION ) DERMOGRAPHISM DIARRHEA DI GEORGE SYNDROME DISSEMINATED INTRA VASCULAR COAGULOPATHY (DIC) (CONSUMPTIVE COAGULOPATHY) DISTENDED ABDOMEN DOWN SYNDROME DROWNING AND NEAR DROWNING DRUG ERUPTIONS E ECZEMA [euro-libris.ro]

• Circumoral Pallor

  pallor; spares nasolabial folds S/P 1-4d → maculopapular rash on extremities, extensor surfaces, trunk (palms/soles us. spared) Gradually fades into lace-like reticular pattern (5-7d) Fever, non-toxic appearing Pallor, lethargy, tachycardia: aplastic [fprmed.com]

  The best-known rash of fifth disease is on the face, which becomes intensely red, especially on the cheeks, with a pale ring around the mouth ("circumoral pallor"). [drreddy.com]

  The rash can look like the redness of a slapped face (figure 2), intensely red on the cheeks with a pale ring around the mouth (circumoral pallor). It may extend to the rest of the body as a lacy rash (figure 3). Sometimes there is itching. [microbiologybook.org]

  The first stage of the rash ( Figure 1A 8 ) presents as erythema of the cheeks (“slapped-cheek” rash) with circumoral pallor. [aafp.org]

• Headache

  However, some children have a low fever and feel mildly ill with a headache and a runny nose for a few days. [merckmanuals.com]

  Definition Contagious infection caused by the human Parvovirus B19 which is most commonly seen in school age children and characterized by fever, headache, and rashes on the face, trunk, and extremities. It is often confused with rubella. [dermis.net]

• Lethargy

  Rash : bright red w/circumoral pallor; spares nasolabial folds S/P 1-4d → maculopapular rash on extremities, extensor surfaces, trunk (palms/soles us. spared) Gradually fades into lace-like reticular pattern (5-7d) Fever, non-toxic appearing Pallor, lethargy [fprmed.com]

  Symptoms include uncontrollable vomiting, often with lethargy, memory loss, disorientation, or delirium. Swelling of the brain may cause seizures, coma, and in severe cases, death. [encyclopedia.com]

  Aplastic crisis usually presents with pallor, weakness, and lethargy, and patients are highly viremic, thereby posing a risk of transmission to others ( 7, 26, 59 ). [cmr.asm.org]

The classical clinical manifestation of erythema infectiosum is usually sufficient to establish diagnosis. However, in pregnant women and in individuals indicating presence of other coexisting symptoms reassurance of correct identification of the causative organism is needed. Several tests are available to correctly identify PV-B19. Enzyme-linked immunosorbent assay (ELISA) is a specific test used to identify IgM that is produced when PV-B19 infects the host. Evaluation of the status of PV-B19 and IgM helps in confirming the diagnosis. Other diagnostic tests comprise radioimmunoassay (RIA), dot blot hybridization, polymerase chain reaction (PCR) and loop-mediated isothermal amplification. In pregnant and immunocompromised patients presenting with symptoms of hemolytic anemia and arthropathy, a complete blood count (CBC) is usually needed [9] [10]. Assessment of maternal alpha-fetoprotein levels along with serial ultrasonography are required in pregnant mothers to find out whether or not the disease has affected fetal growth.

• Leukopenia

  The reduction in the reticulocyte count is occasionally accompanied by leukopenia and thrombocytopenia. [aafp.org]

  Thrombocytopenia, leukopenia, or both may be seen in acute infection, even in immunologically normal hosts. Cases of immune thrombocytopenic purpura, Henoch-Schönlein purpura, and the hemophagocytic syndrome have been attributed to parvovirus B19. [emedicine.com]

Treatment depends upon disease severeness, patient's overall immune health and presence of comorbidities. 

As described earlier, the mild form of erythema infectiosum is usually a benign and self limited illness which often resolves within few weeks without major pharamcological intervention [11]. However, symptomatic pharmacological therapy may be required in the presence of arthralgia and pruritis. Oral analgesics are usually effective in subsiding pain associated with arthralgia while oral antihistamines and topical antipruritic agents (lotions, creams, ointments) are helpful in eradicating rash and discomfort associated with pruritis. Patients are advised to apply sun protection whenever possible as sun exposure can worsen rash. Patients suffering from serious complications such as temporary aplastic anemia require hospitalization and transfusion of blood and blood products.

Erythema infectiosum is self-limited and possesses good prognosis in previously healthy, immunocompetent individuals. However, the disease does not lead to a positive outcome in patients who are immunocompromised or already suffering from reticulocytopenia, hemolytic anemia or aplastic anemia. Prolonged, uncontrolled infection in immunocompromised individuals adversely inhibits multiplication of all progenitor cells. In worst case, this may lead to bone marrow failure. 

The disease can be life threatening in pregnant mothers as the virus easily crosses the placenta and exerts a cytotoxic effect in the fetus causing severe hemolytic anemia, congestive heart failure (CHF) and as a fatal complication hydrops fetalis. 

Erythema infectiosum is a viral disease. The causative organism is human parvovirus B19, also known as erythrovirus b19 or simply PV-B19. The rapidly dividing erythroid cell lines are suppressed in the disease as the virus PV-B19 undergoes division in these cells [2]. The disease is contagious and it is transmitted through respiratory secretion when a PV-B19 infected individual exhales droplets. It can also be passed from a infected mother to her fetus and parenterally through blood transfusion.

Erythema infectiosum is found in people of all races and has been reported to affect Americans, Asians and Europeans equally [3]. The disease shows no gender predominance and can occur equally in both males and females. However, pregnant infected women may be adversely affected by the complications occurring from the disease such as arthropathy. Epidemiological studies have revealed that the incidence of the disease is increased in winter and early spring season [4] and the disease outbreaks rapidly after a period of approximately every 5.5 years affecting about 40% of US population. The reported year of occurrence of the last epidemic was 1998.

As described earlier, erythema infectiosum is caused by a thermostable PV-B19 virus which contains a single strand of DNA [5] and undergoes multiplication by incorporating its DNA in human erythroid progenitor cells [6]. Among all erythroviruses, PV-B19 is the only pathogenic virus known. Once the virus enters the host cell and provokes an immune response, the host cell produces  IgM against the virus along with the formation of immune complexes. These immune complexes are ultimately responsible for producing specific clinical signs of erythema infectiosum by settling into skin and joints of the host. 

Erythema infectiosum is a contagious illness and the risk of transmission is highest before appearance of symptoms during the incubation period of the virus inside host body. The normal incubation period of the disease ranges from 4 to 21 days. Therefore, during this time period the infected individual must be kept isolated to prevent spreading the illness. Once the incubation is completed and symptoms of rash start to appear, isolation is not required any longer [7] [8]. Erythema infectiosum is commonly transmitted through respiratory secretions, when infected droplets produced in saliva and mucosa are spread by breathing out, coughing or sneezing. Teachers, parents, day care workers, school children and other persons who are in close contact with the infected child can develop the disease. 

Erythema infectiosum is a contagious disease, especially during the incubation phase. In the presence of an infected child in school or household, implementation of precautionary measures is required such as frequent hand sanitation and avoiding contact with a patient's respiratory secretions. Pregnant women require special precautions because a PV-B19 infection during pregnancy can adversely affect the fetus when the infection spreads through the placenta. Similarly, pregnant health care workers should not be involved in treating cases of PV-B19 infection associated with immunosuppression or temporary aplastic anemia. 

Erythema infectiosum, also referred to as 'fifth disease', 'slapped cheek disease' and 'turkey slap disease' is a benign, contagious mild childhood disorder caused by the human parvovirus B19 (PV-B19). The disease is characterized by flu-like symptoms and appearance of classic slapped-cheek rash on the face and lace pattern exanthem on the body [1]. Erythema infectiosum is among the five common childhood diseases that are accompanied by rash, hence the name 'fifth disease.' The disease particularly affects children but it can also occur in immunosuppressed adults and pregnant women. Males and females are likewise concerned by erythema infectiosum and it occurs equally among all races. The number of reported cases of the disease increases every 3-4 years.

Erythema infectiosum is a contagious disease that is communicated through inhalation of droplets from mucus and saliva of patients infected with PV-B19. The infected children are prone to spread the illness before the appearance of rash, after which the disease does not spread and patient isolation is not required. Once the erythrovirus B19 enters the host cell, it suppresses erythroid progenitor cells. Consequently, immune reaction is provoked and immunoglobulin antibodies (IgM) are produced. The antibodies can serve as marker in establishing diagnosis of erythema infectiosum in the presence of coexisting diseases. Prodromal symptoms of the disease start to appear a week following exposure to the virus and persist for 2-3 days. A 7-10 days duration devoid of symptoms is followed after which the infection proceeds to give clinical manifestation of flu-like symptoms and characteristic skin rash. Erythema infectiosum can be diagnosed by classical clinical presentation of the disease although specialized diagnostic tests and blood cultures may be required to rule out other suspected diagnoses. Mild cases of the disease typically resolve within few weeks unless complications arise that require aggressive pharmacologic treatment. When necessary, symptomatic management with antipyretics, analgesics and antipruritics may be needed along with increased fluid intake and rest. 

Erythema infectiosum or 'fifth disease' is a childhood illness caused by a virus called human parvovirus B19 (PV-B19). It is a contagious disease that is transmitted from infected patients to healthy children. Erythema infectiosum is characterized by light fever, cold-like symptoms, headache and rash. These symptoms usually appear 4-14 days after the development of the infection. In the later course, slapped cheek rash appears (which is the characteristic of the disease), along with a lace-like rash on rest of the body. The rash is worsened by exposure to sunlight and may be accompanied by itchiness. The mild form of the disease presents usually as a self-limited illness that subsides after few weeks. However, in some cases pain in joints may also occur. 

Erythema infectiosum particularly affects children but adults and pregnant women with weak immune system can also suffer from this disease. It is spread by breathing in droplets from saliva or mucus secretions exhaled by infected patients. If a pregnant woman is infected, the infection may be transferred to the fetus. Erythema infectiosum can be prevented by limiting contact with infected individuals and by maintaining proper hygienic practice (frequent hand washing). Parents of infected children must assure to keep them isolated from other household members in order to prevent spreading of the disease. Pregnant health care workers should also avoid treating patients infected with PV-B19, because once the disease is transmitted to the fetus, it increases the risk of causing life threatening anemia and edema in the unborn child. 

Diagnosis is based on the clinical presentation of the disease and the presence of classical slapped cheek and lace-like rashes. Blood cultures are not usually needed unless the patient has a weak immune system or other illnesses are suspected. 

Erythema infectiosum is a self-limiting disease and in the majority of cases symptomatic management is all that is required. Medicines for fever, pain relief, rash and itchiness are recommended. Severe cases that temporarily affect bone marrow may require the need of injecting blood or blood products. 

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