Erythema Infectiosum / Slapped Cheek Syndrome

What Is Erythema Infectiosum? What Is Slapped Cheek Syndrome?

Eythema infectiosum is also known as parvovirus infection, slapped cheek disease, or fifth disease. It is a disease caused by the parvovirus B19 and includes such symptoms as low-grade fever, tiredness, rash on the cheeks (hence "slapped cheek"), and also a rash all over the person's body.

It is also called fifth disease because it used to be 5th among a common group of childhood diseases with similar rashes - after measles, rubella (German measles), scarlet fever and Dukes' disease.

Parvovirus continues to be a common childhood infection which tends to be mild and requires either very little or no treatment. If a pregnant woman has a parvovirus infection there is a risk of serious health problems for the developing fetus. Patients with a weakened immune system, as well as those with some types of anemias are at a higher risk of complications. Slapped cheek syndrome only affects humans, although some types of parvovirus can affect animals. The virus cannot jump from animal-to-human or human-to-animal.

According to the National Health Service, UK, approximately 6 in every 10 people in the UK have been infected with parvovirus B19 at some time in their lives. It is more likely to infect children between the ages of 4 to 12 years.

The majority of people do not become infected more than once.

What are the symptoms of slapped cheek syndrome?

About one third of all patients do not develop any symptoms. It is common for infected children not to notice they have/had the infection.

Slapped cheek syndrome has an incubation period of about 4 to 20 days. During the contagious stages the patient is unlikely to experience any symptoms. Hence, people may spread the infection to other humans and not know they have it. As soon as the rash appears the patient is not longer contagious.

The following signs and symptoms are possible:

• Slightly elevated body temperature
• Fly-like symptoms
• Runny nose
• Stuffy nose
• Fatigue
• Sore throat
• Nausea and/or diarrhea (less common)
• Abdominal pain (less common)
• Joint pain (less common, usually just in adults)
• Neurological problems (very rare, and if so, just in adults)
• Cardiovascular problems (very rare, and if so, just in adults)
• Blotchy red rash appears on the cheeks. The rash may be itchy, but is very rarely painful.
• The rash may spread to the body, limbs and the palms of the hands and soles of the feet. The rash may take up to three weeks to go away. Some patients may experience a recurrence of the rash if they are exposed to heat or sunlight.

Slapped cheek in pregnancy
If a pregnant woman becomes infected with parvovirus B19 there is a slight risk that it may adversely affect the developing fetus, as well as a slight risk of miscarriage. Fortunately, the majority of women are immune to the parvovirus B19. So, the risk of becoming infected, even if the woman is pregnant, is small.

There is a 3% risk that the fetus develops fetal hydrops if the woman is infected during weeks 9 to 20 of her pregnancy. Fetal hydrops can cause congestive heart failure, as well as a severe form of edema due to severe anemia. It is possible for the baby to recover completely from fetal hydrops and have no long-term health consequences.

Initial phase of parvovirus infection

Some children may develop cold-like symptoms early on, which may last from 5 to 10 days. However, the majority of children will have no symptoms during this phase. Possible symptoms, if they do occur, include:

• Slightly elevated body temperature
• Tiredness
• Itching
• Stomach upset
• Sore throat
• Headache
• Irritability

Subsequent phases

• A blotchy bright red rash may appear, generally on both cheeks.
• The rash may spread to the arms, thighs, buttocks. The rash has a slightly raised appearance and takes on a pink color.
• The rash usually appears towards the end of the illness. Parents and caregivers commonly mistake this rash for a medicine-related rash or some other disease. The rash may appear and disappear intermittently over a period of up to 3 weeks. Exposure to sunlight or high temperatures tend to exacerbate symptoms. Babies, toddlers and older children have similar signs and symptoms.
• Athralgia (joint soreness) - adults tend to experience pain and soreness in their joints, especially the hands, wrists, knees and ankles. Symptoms may persist for weeks, but usually only last for a few days.

What are the causes of slapped cheek syndrome?

The virus spreads form human-to-human through the air, saliva or as a result of close contact with other people. The most common form of transmission is through sneezing or coughing, and sometimes hand-to-hand contact. Consequently, in areas where lots of people congregate, such as schools, kindergartens and nurseries infection can spread rapidly. In a small minority of cases, transmission may occur through blood products.

There are dog and cat versions of the virus, called canine parvovirus and feline panleukopenia virus. Parvovirus B19 infects humans only. You cannot catch slapped cheek syndrome from animals, and animals cannot become infected as a result of contact with humans.

Infected people are contagious during the week before the rash appears. As soon as the rash appears the patient is not contagious and can be among other people.

Although parvovirus mostly infects elementary-aged schoolchildren during the winter and spring months, people of any age may be affected.

How is slapped cheek syndrome diagnosed?

Slapped cheek signs and symptoms are generally easy to detect; so diagnosis is generally straightforward . Tests to confirm the presence of the virus are not generally ordered.

Sometimes a GP (general practitioner, primary care physician) may order a blood test to determine whether there are any antibodies. Pregnant women may have to undergo a blood test, as well as patients with weakened immune systems or chronic red blood cell disorders, such as sickle-cell anemia.

Approximately 50% of all adults are immune to parvovirus infections; probably because of a previous infection during childhood, which may have gone unnoticed.

The following actions will occur, depending on the blood test results:

• Blood test shows the patient is immune - no further action required. The patient cannot become re-infected.
• Blood test determines there was recent parvovirus infection - further tests may be ordered to find out whether any complications require treatment. An example of a complication is anemia.
• Blood test shows a pregnant woman is infected - additional tests may be carried out, including an ultrasound scan and further blood tests. The aim here is to monitor the developing fetus for any complications.

What are the treatment options for slapped cheek syndrome?

In the majority of cases no treatment is required.

• Headache, fevers, and cold-like symptoms - if the patient has headaches, fevers or any discomfort the doctor may recommend Tylenol (paracetamol) or ibuprofen. Children under the age of 16 years must not take aspirin as there is a slight risk of developing Reye's Syndrome, a disease which may harm the liver and brain. For younger children, painkillers in liquid form may be more suitable. Check dosages and frequency of use with a qualified pharmacist, your doctor, or read the instructions in the packet carefully.
• Joint pains and swelling - this usually only affects adults, and the doctor may advise rest, and prescribe ibuprofen or some other anti-inflammatory drug. In the vast majority of cases, such pains and swellings have not long-term consequences and resolve within a few days or weeks.
• Drink and rest - drinking plenty of fluids and getting adequate rest helps ease symptoms and facilitates a faster recovery. The best drink to have is water.
• The rash - treatment aimed at the rash is not usually required.
• Severe anemia - patients with severe anemia may have to be hospitalized and be given blood transfusions.
• Patients with weakened immune systems - patients will most likely receive antibodies via immune globulin.
• Pregnancy - if a woman is infected during her pregnancy the doctor will carefully monitor the baby. If the baby appears to have anemia, congestive heart failure or edema, blood transfusions may be given.

What are the complications of slapped cheek syndrome?

Slapped cheek syndrome hardly ever leads to complications. The following conditions or situations may raise the risk of a complication:

• Pregnancy - any patient who suspects parvovirus B19 infection and is pregnant should see their GP. If a blood test proves positive for parvovirus B19 infection during the first 20 weeks of pregnancy the doctor will monitor the baby through a combination of ultrasound scans and blood tests.
  
  A blood transfusion directly into the baby, if required, will improve his/her chances of coming to full term and surviving (reduces the risk of miscarriage). Blood transfusions are usually recommended if the baby has developed fetal hydrops.
  
  The risk of becoming infected during pregnancy is very small. Even if a pregnant woman becomes infected, the risk of complications for the baby is still small.
• If you have blood abnormalities - such as sickle-cell anemia, infection with parvovirus B19 can result in acute, severe anemia. Children with hereditary anemia are more susceptible to developing severe anemia when infected. Patients will usually be hospitalized and given blood transfusions.
• Patients with weakened immune systems - a patient with a weakened immune system has a higher risk of developing chronic anemia as a result of parvovirus B19 infection and may need to be hospitalized.
• Arthritis - a possible complication of parvovirus B19 infection is arthritis, which may affect the small joints of the hands and feet. Symptoms will be similar to those of rheumatoid arthritis. This complication is much more common in adults than in children. Although symptoms may persist, they rarely continue for more than a few weeks or months. Long-term damage to bones or joints is very rare.

Prevention of slapped cheek syndrome

There is currently no vaccine which protects people from parvovirus B19 infection. Those who have been infected are immune and cannot be infected again.

Good hand hygiene helps stem the spread of infection.