Fifth disease

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fifth disease
Other names: Erythema infectiosum, human erythrovirus infection, slapped cheek syndrome, slapcheek, slap face, slapped face[1][2][3]
Fifth disease.jpg
16-month-old with the typical rash
SpecialtyInfectious disease
SymptomsFever, rash, runny nose[4][5]
ComplicationsAplastic anemia, pain in multiple joints, hydrops fetalis[4]
Usual onset5 to 15 years old[4]
Duration6 weeks[3]
CausesParvovirus B19[4]
Diagnostic methodBased on symptoms[3]
Differential diagnosisMeasles, rubella, roseola, scarlet fever[4]
MedicationParacetamol (acetaminophen), NSAIDs[4]

Fifth disease, also known as erythema infectiosum, is a type of viral infection that most commonly occurs in children.[4] The most common symptoms are a low grade fever and rash.[4] Other symptoms may include joint pain, diarrhea, runny nose, vomiting, and headache.[4][5] The rash generally starts in the latter part of the infection, involves the cheeks and spreads to chest and arms.[4] Complications may include aplastic anemia, pain in multiple joints, and during pregnancy hydrops fetalis.[4]

It is caused by infection by parvovirus B19.[6] It is typically spread via the respiratory route, though may also spread from mother to child during pregnancy and via blood transfusions.[4] Diagnosis is usually based on the symptoms, though it may be confirmed with blood tests.[3]

Treatment is symptomatic and supportive which may include paracetamol (acetaminophen) and NSAIDs.[4] It is common and typically occurs in those between the ages of 5 and 15.[4][3] Early descriptions of the disease data from at least 1889 by Tschamer and maybe as early as 1799 by Robert Willan.[7][8] In 1905 it was classified as the "fifth rash disease" in the standard list of rash-causing childhood diseases.[8][5]

Signs and symptoms

Fifth disease starts with a low-grade fever, headache, rash, and cold-like symptoms, such as a runny or stuffy nose. These symptoms pass, then a few days later, the rash appears. The bright red rash most commonly appears in the face, particularly the cheeks. This is a defining symptom of the infection in children (hence the name "slapped cheek disease"). Occasionally, the rash will extend over the bridge of the nose or around the mouth. In addition to red cheeks, children often develop a red, lacy rash on the rest of the body, with the upper arms, torso, and legs being the most common locations. The rash typically lasts a few days and may itch; some cases have been known to last for several weeks. Patients are usually no longer infectious once the rash has appeared.[1][2] The rash usually may be itchy especially on the bottom of the feet.[5]

Onset of symptoms is generally within two weeks of exposure.[5]

Teenagers and adults may present with a self-limited arthritis. It manifests in painful swelling of the joints that feels similar to arthritis. Older children and adults with fifth disease may have difficulty in walking and in bending joints such as wrists, knees, ankles, fingers, and shoulders.[1][2]


The disease is usually mild,[10] but in certain risk groups, it can have serious consequences:


Fifth disease is transmitted primarily by respiratory secretions (saliva, mucus, etc.), but can also be spread by contact with infected blood. The incubation period (the time between the initial infection and the onset of symptoms) is usually between 4 and 21 days. Individuals with fifth disease are most infectious before the onset of symptoms. Typically, school children, day-care workers, teachers, and parents are most likely to be exposed to the virus. When symptoms are evident, the risk of transmission is small; therefore, symptomatic individuals do not need to be isolated.[1][2]


There is no vaccine or medicine that can prevent the disease.[5] The risk of disease can be reduced by washing hands, covering the mouth when you cough, not touching their eyes, nose, or mouth, avoiding close contact with people who are sick, and staying home when you are sick.[5]


Treatment is supportive, as the infection is generally self-limiting. Medications used to help with symptoms include NSAIDs and paracetamol (acetaminophine).


Any age may be affected, although it is most common in children aged 5 to 15 years.[12] By the time adulthood is reached, about half the population will have become immune following infection at some time in their past.[1][2] Outbreaks can arise especially in nursery schools, preschools, and elementary schools. Infection is an occupational risk for school and day-care personnel.[13] No vaccine is available for human parvovirus B19,[2] though attempts have been made to develop one.[14]


A disease presenting similarly,[7] was first described by Robert Willan in 1799 as "rubeola, sine catarrho". It was better defined by Anton Tschamer in 1889 as a rubella variant (Ortliche Rotheln), identified as a distinct condition in 1896 by Theodor Escherich, and given the name "erythema infectiosum" in 1899.[15] The term "Fifth disease" was coined in 1905 by the Russian-French physician Léon Cheinisse (1871-1924), who proposed a numbered classification of the six most common childhood exanthems.[16][7][17][18][19] The virus was first described in 1957 at the University of Pennsylvania by Werner, Brachman et al.[20]


  1. 1.0 1.1 1.2 1.3 1.4 1.5 Sabella C, Goldfarb J (October 1999). "Parvovirus B19 infections". Am Fam Physician. 60 (5): 1455–60. PMID 10524489. Retrieved 2009-11-06.
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Servey JT, Reamy BV, Hodge J (February 2007). "Clinical presentations of parvovirus B19 infection". Am Fam Physician. 75 (3): 373–6. PMID 17304869. Retrieved 2009-11-06.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 "Erythema infectiosum | DermNet NZ". Retrieved 22 October 2020.
  4. 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 Kostolansky, S; Waymack, JR (January 2020). "Erythema Infectiosum (Fifth Disease)". PMID 30020681. Cite journal requires |journal= (help)
  5. 5.0 5.1 5.2 5.3 5.4 5.5 5.6 "Parvovirus B19 | About Fifth Disease | CDC". 26 November 2019. Retrieved 23 October 2020.
  6. Weir E (March 2005). "Parvovirus B19 infection: fifth disease and more". CMAJ. 172 (6): 743. doi:10.1503/cmaj.045293. PMC 552884. PMID 15767606.
  7. 7.0 7.1 7.2 Morens, David M. (6 August 1982). "Fifth Disease: Still Hazy After All These Years". JAMA: The Journal of the American Medical Association. 248 (5): 553. doi:10.1001/jama.1982.03330050035026.
  8. 8.0 8.1 Zuckerman, Arie J.; Banatvala, Jangu E.; Pattison, John R.; Griffiths, Paul; Schoub, Barry (2004). Principles and Practice of Clinical Virology. John Wiley & Sons. p. 710. ISBN 978-0-470-02096-8.
  9. "Erythema infectiosum images | DermNet NZ". Retrieved 22 October 2020.
  10. Mankuta D, Bar-Oz B, Koren G (March 1999). "Erythema infectiosum (fifth disease) and pregnancy". Can Fam Physician. 45: 603–5. PMC 2328398. PMID 10099795.
  11. Yoto Y; et al. (2003). "Retrospective study on the influence of human parvovirus B19 infection among children with malignant diseases". Acta Haematol. 90 (1): 8–12. doi:10.1159/000204365. PMID 8237278.
  12. Kwon, Kenneth T (March 19, 2009). "Pediatrics, Fifth Disease or Erythema Infectiosum". eMedicine. Retrieved November 7, 2009.
  13. Gillespie, S. M.; Cartter, M. L.; Asch, S; Rokos, J. B.; Gary, G. W.; Tsou, C. J.; Hall, D. B.; Anderson, L. J.; Hurwitz, E. S. (1990). "Occupational risk of human parvovirus B19 infection for school and day-care personnel during an outbreak of erythema infectiosum". JAMA. 263 (15): 2061–5. doi:10.1001/jama.1990.03440150069028. PMID 2157074.
  14. Ballou WR, Reed JL, Noble W, Young NS, Koenig S (2003). "Safety and immunogenicity of a recombinant parvovirus B19 vaccine formulated with MF59C.1". J Infect Dis. 187 (4): 675–8. doi:10.1086/368382. PMID 12599085.
  15. Altman, Lawrence K (November 30, 1982). "THE DOCTOR'S WORLD". The New York Times. Retrieved November 7, 2009.
  16. Robert R. Briney. Primary Cutaneous Actinomycosis
  17. Dictionary of Virology
  18. St. Louis Courier of Medicine (1906)
  19. Principles and Practice of Clinical Virology
  20. Werner, Georges H.; Brachman, Philip S.; Ketler, Albert; Scully, John; Rake, Geoffrey (1957). "A new viral agent associated with Erythema Infectiosum". Viruses in Search of Disease. Annals of the New York Academy of Sciences. 67. pp. 338–345. doi:10.1111/j.1749-6632.1957.tb46058.x. PMID 13411972.

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