Parvovirus B19Dz

Synonym: “Fifth’s disease” or erythema infectiosum.

ICD-9 Code: Fifth’s disease, 057.0; arthropathy associated with viral diseases, 711.5.

Definition: Human Parvovirus B19 is the most common viral cause of arthralgias and polyarthritis in adults. Fifth’s disease is also seen in children.

Pathology: Parvovirus has tissue tropism for red blood cell progenitors. Parvovirus B19 has been isolated from bone marrow and synovium of affected individuals by molecular biologic techniques. Viral persistence may possibly explain those with chronic arthropathy.

Demographics: Parvovirus B19 is nearly endemic among school children. As many as 60% of adults in the United States demonstrate serologic evidence of past infection. Periodic outbreaks occur most commonly in late winter and spring. Young to middle-aged adult women are at highest risk of Parvovirus B19 arthropathy.

Cardinal Findings: Children typically manifest a bright red “slapped cheek” rash and may be diagnosed with erythema infectiosum. Less commonly, a lacy erythematous eruption may be seen on the torso or extremities. The rash may be accompanied by mild constitutional symptoms and low-grade fever. Some children may be asymptomatic.
Adults infected with Parvovirus B19 develop a flu-like illness. A mild maculopapular rash of the extremities may be seen. Arthralgia or arthritis is seen in 20% of patients. An acute polyarthritis is less common and may persist for weeks to months in some. Symmetric arthritis affecting the knee, proximal interphalangeal joint, wrist, or ankles may resemble early RA.

Uncommon Findings: Chronic arthropathy is a rare result of Parvovirus B19 infection. Although RA and SLE may occur after Parvovirus B19 infection, but no causal relationship is established. Other complications of Parvovirus B19 include aplastic crises, hemolytic anemia, bone marrow suppression in patients with immunodeficiency, and hydrops fetalis.

Keys to Diagnosis: Abrupt-onset symmetric polyarthritis in young women exposed to children infected with erythema infectiosum should suggest Parvovirus B19 infection.

Diagnostic Testing: Anemia may result from diminished red blood cell production. High-titer anti-IgM antibodies on ELISA help to confirm the diagnosis. However, IgM is only elevated for approximately 2 to 3 months after an attack. Positive Parvovirus B19 IgG antibody is consistent with previous exposure but does not help establish a diagnosis because of the high prevalence of seroconversion in the general population. RF and ANA are usually absent or transiently detected in low titer. Radiographic erosions are uncommon.

Therapy: Analgesics are given for joint pain in adults. NSAIDs may occasionally be helpful. Temporary supportive care is required for many because infection is self-limiting. For rare patients with persistent polyarthritis, therapy is similar to that used for RA.

Prognosis: In most patients, symptoms resolve within a couple of weeks. A subset of individuals develop protracted or intermittent musculoskeletal symptoms that may last months. Many patients meet classification criteria for RA at some point in the disease course.

BIBLIOGRAPHY

Gran JT, Johnsen V, Myklebust G, et al. The variable clinical picture of arthritis induced by human Parvovirus B19: report ofseven adult cases and review of the literature. Scand J Rheumatol 1995;24:174–179. PMID:7777831

Naides SJ, Scharosch LL, Foto F, et al. Rheumatologic manifestations of human Parvovirus B19 infection in adults: initial two-year clinical experience. Arthritis Rheum 1990;33: 1297–1307. PMID:2169746