Human Parvovirus B19 Infection which First Presented with Petechial Hemorrhage, Followed by Papular-Purpuric Gloves and Socks Syndrome and Erythema Infectiosum

Abstract

A case of human parvovirus B19 (B19) infection is reported. A 6-year-old previously healthy girl was admitted to our hospital complaining of slight fever and petechial hemorrhage on her neck, trunk and the proximal parts of extremities. On admission, the platelet count was within normal range (180 x 10(3)/microliter) but white blood cells and reticulocytes were moderately suppressed (2.4 x 10(3)/microliter and 1@1000, respectively). The purpura disappeared in a week and the blood cell counts fully recovered without any specific treatment. Detection of B19 DNA and anti-B19 IgM antibody in the serum on admission led to the final diagnosis. Since the cellular receptor for B19, the blood group P antigen, is expressed on vascular endothelial cells as well as erythroid progenitor cells, the purpura was considered to be the result of direct vascular injury. She was very unique as she subsequently exhibited papular-purpuric gloves and socks syndrome and erythema infectiosum during follow-up. This case may provide a new insight into the pathogenesis of cutaneous manifestations of B19 infection.

Generalized Petechial Rashes in Children During a Parvovirus B19 Outbreak

“…21 Although erythema infectiosum did develop in 2 of our case patients, this occurred long after disappearance of their petechial rashes. This sequence-petechial rash followed by erythema infectiosum-has been previously described 3,6 and further distinguishes petechial rash in our patients from erythema infectiosum.…”

“…Petechiae rashes in some of our cases had focal accentuation (in the distal extremities, groin, or axillae), but petechiae were widely distributed in all cases and, in this respect, more closely resembled the generalized rashes described in a few case reports. [1][2][3]10 On the basis of the clinical characteristics of our cases, it seems that parvovirus-associated petechial rash is closely linked to the viremic phase of parvovirus infection. Our case patients typically had fever, systemic symptoms, leukopenia (and occasional thrombocytopenia), and detectable parvovirus DNA in their blood, and acutephase serum tests indicated that a specific antibody response had either not yet developed (IgM-negative) or was just developing (IgM-positive/IgGnegative).…”

“…Most case reports emphasized the distinctively focal ("gloves and socks," 8 "bathing trunk," 5,7 or "acropetechial" 9 ) distribution of these atypical rashes, and only a few reports have described generalized petechial rashes associated with parvovirus infection. [1][2][3]10 We could find no description of an outbreak of parvovirus-associated petechial rash in the English-language medical literature.…”

“…This is surprising because previous English-language reports of parvovirusassociated petechial rashes described only solitary cases or small numbers of seemingly sporadic cases, 1-7 although the authors of 1 report did refer (in Japanese) to an apparent cluster of 8 pediatric cases examined at a single Japanese hospital during a period of 6 months. 3 Parvovirus-associated petechial rashes may be more common than generally appreciated. Illnesses that are characterized by fever and petechial rash are, themselves, not rare in children 11 and can be caused by a wide variety of viral, bacterial, and rickettsial agents.…”

“…These parvovirus-associated hemorrhagic rashes seem to be uncommon, and published reports have described only solitary or sporadic cases (reviewed by McNeely et al 1 and additionally reported by others [2][3][4][5][6][7]. Most case reports emphasized the distinctively focal ("gloves and socks," 8 "bathing trunk," 5,7 or "acropetechial" 9 ) distribution of these atypical rashes, and only a few reports have described generalized petechial rashes associated with parvovirus infection.…”