Download Atypical exanthems associated with parvovirus B19 infection

Le Infezioni in Medicina, n. 3, 283-284, 2015
Lettera all’Editore / Letter to the Editor
283
Atypical exanthems associated
with parvovirus B19 infection:
similarities and differences
between adults and children
Esantemi atipici associati all’infezione da parvovirus B19:
similitudini e differenze tra adulti e bambini
Francesco Drago, Giulia Ciccarese, Sanja Javor, Emanuele Cozzani, Aurora Parodi
IRCCS A.O.U. San Martino-IST DISSAL, Department of Dermatology, Italy
Dear Editor,
we read with interest the article by Tuccio et al.
about a pediatric case of petechial rash associated with Parvovirus B19 (PB19) infection and we
would like to report our experience on PB19-related atypical exanthems in children and adults [1].
In our series of 120 consecutive children with
atypical exanthems seen between 2009 and 2014,
6 of them (5.0%) were related to PB19 infection.
They were 4 males and 2 females with an average
age of 9 years (range 7-10 years).
The slapped cheek sign, the initial manifestation
of the fifth disease (erythema infectiosum), was
present in almost all patients (5/6) and in one
of them it was very fleeting, lasting less than 24
hours.
Three patients had a maculopapular exanthema
with petechiae involving the trunk and lower
limbs (2 cases) or only the legs (1 case). The other
patients presented a petechial exanthema exclusively on the lower extremities. Palms and soles
were invariably spared.
Only the two children with widespread maculopapular exanthemas complained of a moderate
itching.
Corresponding author
Giulia Ciccarese
E-mail: [email protected]
Enanthems with a macular-petechial pattern were
observed in 5 patients (83%) on the soft palate and
oropharyngeal pillars.
Four children (67%) developed a low grade fever
(37.8°C) and one of them had also headache but
neither arthralgias nor other prodromal or accompanying symptoms were encountered.
In all patients, laboratory investigations resulted
normal and serology by EIA showed PB19 virusspecific IgM antibodies and low but increasing
levels of PB19 virus-specific IgM antibodies and
low but increasing levels of PB19 virus-specific
IgG antibodies, indicating a primary infection.
Resolution of the rash and symptoms was obtained in about two weeks.
In our series of 270 consecutive adult patients
with atypical exanthemas, PB19 active infections
were reported in 14 cases (5.8%), a frequency that
is nearly the same observed in children (5.0%) [2,
3]. In 79% of the patients (11/14) the exanthema
consisted of maculo-papular lesions primarily
on the trunk, neck and extensor surfaces of the
extremities. The lesions had some central fading
that, in 4 patients, gave them a lacy or reticulated
appearance. Purpuric lesions was shared by all
patients, when examined carefully, as predominant pattern or interspersed among the maculopapular lesions.
Palms and soles were always spared. Noteworthy, in adult patients we did never find the typical
“slapped cheek” appearance that characterizes
284 F. Drago, et al.
the exanthema in children. Moreover, two adult
patients (14%) had a periflexural involvement
with an asymmetrical distribution diagnosed as
“unilateral laterothoracic exanthem” (ULE) and
one of them had also hepatitis due to PB19 infection [2, 4]. The ULE has rarely been reported in
children with PB19 infection [5, 6] .
Enanthem was observed in 71% of the adult patients, their most frequent pattern being maculopapular with petechiae whereas it was present in
all but one of our children.
Regarding the systemic symptoms, 79% of the
adults developed diffuse arthralgias and among
them, we identified a case of remitting seronegative symmetrical synovitis with pitting edema
(RS3PE), that occurred as an erythematous-papular-purpuric eruption on the trunk and extremities [2]. RS3PE is a rare syndrome presenting with
acute symmetrical synovitis of the wrists, carpal
joints and fingers with pain, swelling and pitting
edema of the dorsa of the hands (“boxing-glove
hand”) and/or feet. The inflammatory indexes
are always elevated, but the rheumatoid factor is
negative. The syndrome may be idiopathic or associated with neurologic disorders, malignancies,
connective tissue diseases and infectious agents
like PB19 [7]. None of our PB19 pediatric patients
developed arthralgias and RS3PE has never been
reported in children.
A low grade fever was present in 67% of children
whereas it has never been reported in adults [2].
Laboratory investigations, especially inflammatory indexes and liver enzymes, may be altered in
adult patients whereas they always resulted normal in our children [4, 7].
Serology disclosed PB19 IgM antibodies in all our
children who experienced a primary infection.
Conversely, the specific IgM antibodies were detected in 86% of adult patients and detection of
B19 DNA in serum by polymerase chain reaction
(PCR) in 79% of them. Noteworthy, in adults, even
in immunocompetent persons, a PB19 persistent
infection in the bone marrow and low plasma levels of DNA has been reported several years after
the primary infection focusing on the possibility
of viral reactivation.
In conclusion, the PB19 active infection in chil-
dren, that is usually a primary infection, may
cause either the typical fifth disease or atypical
exanthems, presenting with a petechial pattern
and petechial enanthems, usually with negligible
systemic symptoms. On the contrary, in adult patients, PB19 active infection is commonly due to a
viral reactivation rather than a primary infection,
therefore it is useful to study not only serology
but also PB19 serum viremia, that is a marker of
active infection. Moreover, also in adults, PB19
infection may present with an atypical exanthem
with purpuric and maculo-papular lesions often
associated with maculo-papular-petechial enanthems and arthralgias.
Conflict of interest and funding
This article has no funding sources.
The authors have no conflict of interest to declare.
Keywords: exanthem, Parvovirus B19, maculo-papular eruption, purpuric lesions, enanthem.
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