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Erythema Infectiosum

Fifth Disease in the 1st Phase of the Disease

Erythema infectiosum is a Latin name (meaning 'infectious redness') for a childhood illness caused by an erythrovirus called human parvovirus B19 (PV-B19). 


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. 

  • Over a few weeks, 69 children (13%) enrolled in a private school manifested an erythematous and migratory rash, most commonly on the extremities, along with fever or other systemic or respiratory symptoms.[ncbi.nlm.nih.gov]
  • A 9-year-old child presented with moderate to high grade fever, mild anemia, and erythematous rash involving face, trunks and limbs associated with arthralgia, myalgia and myositis.[ncbi.nlm.nih.gov]
  • The acute disease is often associated with fever, malaise, and arthralgias.[medical-dictionary.thefreedictionary.com]
  • Facts : Parvovirus B19 History / PE : PRODROME None, fever is often absent or low grade RASH "Slapped cheek" Worsens with fever and sun exposure Complications : Arthritis Hemolytic anemia Aplastic crisis (eg. sickle cell, hereditary spherocytosis ) Congential[medlibes.com]
  • Bone marrow biopsy, which was performed to evaluate the anemia, was consistent with acute lymphocytic leukemia. Persistent parvovirus B19 infection may be connected with immunosuppression.[ncbi.nlm.nih.gov]
  • Sixty-five subjects in the acute phase of erythema infectiosum were involved, and in addition 22 serum samples from seven subjects with B19V-associated aplastic crisis complicating chronic hemolytic anemia were also analyzed.[ncbi.nlm.nih.gov]
  • 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.[symptoma.com]
  • A 9-year-old child presented with moderate to high grade fever, mild anemia, and erythematous rash involving face, trunks and limbs associated with arthralgia, myalgia and myositis.[ncbi.nlm.nih.gov]
  • Arthropathy, aplastic anemia us. resolve w/in 2-4wks (rarely may last yrs) Aplastic crisis rare once rash appears Chronic anemia in immunocompromised pts until immunity normalizes Symptoms Incubation period 4-21d (usual 7-10d) Prodrome: 1wk s/p exposure[fprmed.com]
  • 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]
  • Typical initial manifestations are nonspecific flu-like symptoms (eg, low-grade fever, slight malaise).[merckmanuals.com]
  • It is a mild, self-limiting 'slapped-cheek' facial rash with low-grade fever and malaise in immunocompetent children.[genome.jp]
  • Mild headache , fever, general malaise. Sometimes nausea, abdominal pain and joint stiffness can occur.[health.ccm.net]
  • Some adults may have fatigue, malaise, and depression for weeks after the infection. Asymptomatic infection can certainly occur in adults as well as in children. In one outbreak, 26 percent of adults were reported to be asymptomatic.[dermaamin.com]
  • The following are most likely observed: Fever, headache, coryza, abdominal pain, sore throat and malaise on the first week.[nursingcrib.com]
Pediatric Disorder
  • […] unusual presenting features for over 300 pediatric disorders.[euro-libris.ro]
  • 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]
  • Patients may have headache, pharyngitis, fever, malaise, myalgias, coryza, diarrhea, nausea, cough, and conjunctivitis coinciding with the rash. Approximately 10 percent of children with erythema infectiosum develop arthralgias or arthritis.[dermaamin.com]
  • Leg pain and arthralgia occurred in five of the children.[ncbi.nlm.nih.gov]
  • A 9-year-old child presented with moderate to high grade fever, mild anemia, and erythematous rash involving face, trunks and limbs associated with arthralgia, myalgia and myositis.[ncbi.nlm.nih.gov]
  • In adult parvovirus B19 infection may lead to arthritis and arthralgia. Pregnant women who predispose to parvovirus B 19 may present with generalized fetal anemia and congestive heart failure or known as hydrops fetalis.[medicalrealm.net]
  • Adults, more than children, may report arthritis and arthralgias. Most cases do not require specific treatment beyond symptomatic therapy and reassurance.[bestpractice.bmj.com]
  • However, symptomatic pharmacological therapy may be required in the presence of arthralgia and pruritis.[symptoma.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]
  • Symptoms include stiffness in the morning, redness and swelling of the same joints or both sides symmetrical" arthritis (involving the knees, fingers, and wrists).[omicsonline.org]
  • 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]
  • The most constant clinical sign was reticular exanthema on the limbs, present in 100% of the cases, followed by 89.77% of cheek erythema.[ncbi.nlm.nih.gov]
  • Sticker disease - a mild infectious exanthema of childhood caused by Parvovirus B19.[medical-dictionary.thefreedictionary.com]
  • Erythema infectiosum is a mildly infectious and contagious exanthema of assumed viral origin, occurring in children and young adults.[jamanetwork.com]
  • 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 was present in 9.09% of the children, mild constitutional symptoms in 5.68% and palpable lymph glands in 3.41% of the children. In all the cases the course of the disease was without complications.[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]
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 crisis[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]
  • On examination, he had an erythematous rash over the face with relative circumoral pallor. An erythematous maculopapular rash was also present over the entire trunk and the extremities.[bmcpediatr.biomedcentral.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]
  • […] 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]
  • The constitutional symptoms of erythema infectiosum, such as headache, are generally mild. The initial facial erythema progresses to the trunk and extremities as maculopapular lesions that evolve into a lacy, reticulated appearance.[consultant360.com]
  • Children who get the virus may develop a fever , headache , runny nose, and a characteristic red rash on the face ("slapped cheek rash"). The rash may spread to other parts of the body including the extremities, buttocks, chest, and back.[emedicinehealth.com]
  • Fifth disease: signs/symptoms 20% of children and adults have a subclinical infection. 1. prodromal: runny nose, headache, and fever like the common cold and is contagious; 2. invasion: red rash on the face called "slapped cheek ", more common in children[quizlet.com]


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.

Human Parvovirus B19
  • Her human parvovirus B19 serum IgM titer was elevated at 3.50, indicating current infection.[ncbi.nlm.nih.gov]
  • A report is presented of a patient with neonatal erythema infectiosum who developed petechiae, transient thrombocytopenia and transient cardiac failure due to transplacental transmission of human parvovirus B19 (HPV B19) infection.[ncbi.nlm.nih.gov]
  • Human parvovirus B19 has also been implicated as the etiologic agent in erythema infectiosum, a childhood exanthem that may occur in adults in association with joint manifestations.[ncbi.nlm.nih.gov]
  • Examination of 6 serum specimens obtained during the subsequent investigation demonstrated evidence of recent Human Parvovirus B19 infection in 3 children and 1 teacher. No evidence of recent rubella virus infection was found.[ncbi.nlm.nih.gov]
  • Human parvovirus B19, the cause of erythema infectiosum, has recently been associated with adverse fetal outcomes.[ncbi.nlm.nih.gov]


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.

Sex distribution
Age distribution


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. 

Patient Information

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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  2. Quattrocchi S, Ruprecht N, Bönsch C, et al. Characterization of the early steps of human parvovirus B19 Infection. J Virol. 2012;86(17):9274-9284.
  3. Leads from the MMWR. Risks associated with human parvovirus B19 infection. JAMA. 1989;261;1406-1408.
  4. American Academy of Pediatrics. Red Book: 2006 Report on the Committee of Infectious Diseases. 2006;484-487.
  5. Anderson MJ, Higgins PG, Davis LR, et al. Experimental parvoviral infection in humans. J Infect Dis. 1985;152(2):257-265.
  6. Cossart YE, Field AM, Cant B, Widdows D. Parvovirus-like particles in human sera. Lancet. 1975;1(7898):72-73
  7. Young N, Brown KE. Parvovirus B19. N Engl J Med. 2004; 350(6):586–597.
  8. Soulie JC. Cardiac involvement in fetal Parvovirus B19 infection. Pathol Biol Paris. 1995;43(5):416- 419.
  9. Yamada Y, Itoh M, Yoshida M. Sensitive and rapid diagnosis of human parvovirus B19 infection by loop-mediated isothermal amplification. Br J Dermatol. 2006;155:50-55.
  10. Corcoran A, Doyle S. Advances in the biology, diagnosis and host-pathogen interactions of parvovirus B19. J Med Microbiol. 2004;53(6):459-475
  11. Revilla Grande AI, Carro Garcia T, Sanchez de Dios M, Galan Calvo MJ, Nebreda Mayoral T. [Outbreak of infectious erythema at a urban health center]. Aten Primaria. 2000; 26(3):172-175.

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Last updated: 2018-06-22 02:48