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Infection by human parvovirus B19: “gloves and socks” papular purpuric syndrome
Diagnostic Microbiology and Infectious Disease 36 (2000) 209 –210
Case Report
Infection by human parvovirus B19: “gloves and socks” papular purpuric syndrome Prudencio Martı´nez–Martı´neza,*, Angel Maran˜o´nb a
Department of Microbiology, University Hospital of Valladolid, Valladolid, Spain Department of Internal Medicine, University Hospital of Valladolid, Valladolid, Spain
b
Received 22 February 1999; received in revised form 3 November 1999
Abstract Human parvovirus B19 is the cause of erythema infectiosum a benign and self-limited infection, but sometimes the virus causes an acute and self-limiting dermatosis. It consists of a edema and erythema of the hands and feet in a gloves and sock distribution and is associated with oral lesions and fever. We report a case of a “gloves and socks” infection by human parvovirus B19. © 2000 Elsevier Science Inc. All rights reserved.
1. Introduction Human parvovirus B19 has been identified as the cause of erythema infectiosum also known as fifth disease (Shapiro, 1965; Anderson et al., 1983). The virus affects mainly to school-aged children, usually among these it causes outbreaks characterized by the typical rash of the erythema infectiosum (Gillespie et al., 1990). It has also been associated with arthralgia (Balkhy et al. 1998), aplastic crisis (Carper and Kurtzman, 1996) and hidrops and death fetal (Levy et al., 1997). This report describes an infection by human parvovirus B19 “gloves and socks” papular purpuric syndrome.
2. Case report A 27-year-old male presented to University Hospital of Valladolid with a painful, pruriginous, purplish vasculitis of sudden onset, 48-h-old, affecting his extremities. It was highly localized, more prominent on the palms than on the backs of his hands and more prominent on the tops than on the soles of his feet, and lack-like in appearance. Purplish vasculitic lesions were also observed where his thighs met his trunk, in his armpits and on his chest, distributed over * Corresponding author. Tel.: ⫹696-400-921; fax: ⫹91-358-1142. E-mail address: [email protected]. (P. Martı´nez–Martı´nez).
the decubitus zone. Accompanying this vasculitis, the patient reported chills, asthenia, general malaise, pain upon eating, and a fever of 39.8°C that did not remit when he took antipyretics (acetaminophen). He showed no meningeal signs, but he did exhibit painful rolling retroarticular, submaxillary, bilateral, and supraclavicular laterocervical adenopathy, although it was more intense and painful on the right-hand side. The patient, a heterosexual with a steady sexual partner at that time, a car salesman, and bouncer by profession who was also studying law, reported having received no insect bites nor having traveled abroad in recent months. Twenty-four hours after hospitalization, the oral mucus displayed an enanthema on the hard palate, vesicular aphthoid lesions on the soft palate and pharynx, as well as edema and vesiculation on the lips and around the mouth that eventually prevented the patient from opening his mouth and taking solid foods. From among the analytic data taken on serum biochemistry, blood count, hemostasis, urine sediment, lymphocyte population, blood cultures, pharyngeal smear, urine culture, and ASLO taken at the patient’s emergency registration, the only item proving abnormal was the patient’s lymphocyte percentage (6.1%), which two days later rose to 14.6% whereas the leukocyte total fell to 4410 (5670 leukocytes at hospitalization). The number of platelets did the same, settling at 120 000 compared to the 152 000 present at first. A serological study for the following bacteria and viruses was also run: Treponema pallidum, rickettsias, HIV, HCV,
0732-8893/00/$ – see front matter © 2000 Elsevier Science Inc. All rights reserved. PII: S 0 7 3 2 - 8 8 9 3 ( 0 0 ) 0 0 1 3 3 - 9
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P. Martı´nez–Martı´nez / Diagnostic Microbiology and Infectious Disease 36 (2000) 209 –210
HBV, HAV, CMV, Epstein–Barr, Coxsackie A and B, ECHO virus, human parvovirus B19, varicella-zoster virus, rubella, and measles. All were nondiagnostic except the human parvovirus B19. The detection in serum of IgM and IgG antibodies for human parvovirus B19 were realized with a sandwich enzyme immunoassay (Parvovirus B19 Enzyme Immunoassay for IgM and IgG, respectively, Biotrin, France). In the first serum (three days after on set of illness) was detected a low positive IgM (0.650 Optical Density, OD), whereas in the second serum taken nine days after on set of illness was detected a high positive IgM (1.667 OD). The IgG displayed a seroconversion (1° serum: 0.132 OD; 2° serum: 0.414 OD). The pre- and post-samples for IgM and IgG were tested at the same time. Also, in the first serum was detected some slight reactivity for the HIV p24 antigen (70 pg/ml) that was not confirmed by neutralization. The biopsy showed a small-vessel leukocytoclastic vasculitis. Antipyretic (acetaminophen) and broad-spectrum antibiotic (erythromycin 500 mg/8 h) treatment was applied for three days, and the lesions remitted in the days thereafter. The patient remained fever-free as of the fourth day of hospitalization.
3. Discussion The “gloves and socks” papular purpuric syndrome was described by Harms et al. (1990). Nevertheless, it was Bagot and Revuz (1991) who related the existence of a primary human parvovirus B19 infection with this syndrome. At all events, not all cases of this syndrome are due to human parvovirus B19 (Hjorther and Hansen, 1996), and therefore we had to run a differential diagnostic with other infectious agents how bacterial infections such as syphilis (secondary syphilis), and rickettsial diseases (Rickettsia conorii), although he recalled no tick bites or rural habits. Traveling abroad would have obliged us to test for erhlichia infection as well (Fisbein et al., 1994). The negative pharynx culture for group-A streptococcus allowed us to rule out scarlet fever. Having eliminated the bacterial agents, we had to search among the viral agents, especially cytomegalovirus, Epstein–Barr, HBV, Coxsackie A and B, and ECHO virus (Cherry, 1993). Lastly, there are complaints of noninfectious origin that must be considered, such as Kawasaki disease, lupus erythematosus, reactions to medicines and environmental allergies, and secondary hives after the administration of heroin. The laboratory results confirmed the diagnosis of acute human parvovirus B19 infection (IgM-EIA). This fact was reinforced by the detection of a seroconversion for IgGEIA. IgM is usually detected within three days after the onset of the symptoms of viremia, and IgG several days
later. After a month, IgM levels begin to decline. IgG levels vary significantly from patient to patient, so whether it grows or not can probably not be used to rule out a recent infection (Skeikh et al., 1992). In immunocompromised patients’ serum, immunoglobulins (IgM and IgG) may be absent or present intermittently, so the use of hybridization and Polymerase Chain Reaction techniques is recommended for a definitive diagnosis. The patient’s jobs and activities could have favored his infection due to his contact with such large numbers of potentially infectious young individuals. In fact, school cafeteria workers and the personnel of nurseries and schools seem to display a higher risk to acquire this infection. This may occur through fomites (e.g. plates and eating utensils), direct contact or large-particle aerosols belonging to students (Gillespie, 1990). In general, human parvovirus B19 infection in immunocompetent individuals tends to cause a benign, self-limited infection that requires no more than supportive treatment. Solely on very rare occasions can a “gloves and socks” case similar to this be observed. In fact, only about 29 cases have been published to date.
References Anderson, M. J., Jones, S. E., Fisher-Hoch, S. P., Lewis, E., Hall, S. M., Bartlett, C. L. R., Cohen, B. J., Mortimer, P. P., & Pereira, M. S. (1983). Human parvovirus: the cause of erythema infectiosum (fifth disease)? Lancet 1:1378. Bagot, M., & Revuz, J. (1991). Papular-purpuric “gloves and socks” syndrome: primary infection with parvovirus B19? J Am Acad Dermatol 25:341. Balkhy, H. H., Sabella, C., & Goldfarb, J. (1998). Parvovirus: a review. Bull Rheum Dis 47:4 –9. Carper, E., & Kurtzman, G. J. (1996). Human parvovirus B19 infection. Curr Opin Hematol 3:111–117. Cherry, J. D. (1993). Contemporary infectious exanthems. CID 16:197– 199. Fisbein, D. B., Dawson, J. E., & Robinson, L. E. (1994). Human ehrlichiosis in the United States. Ann Intern Med 120:736 –743. 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: 2061–2065. Harms, M., Feldmann, & Saurat, J. H. (1990). Papular-purpuric “gloves and socks” syndrome. J Am Acad Dermatol 23:850 – 854. Hjorther, A. B., & Hansen, E. R. (1996). “Glove-sock” syndrome. A new disease entity. Ugeskrift for Laeger 158:1380 –1381. Levy, R., Weissman, A., Blomberg, G., & Hagay, Z. J. (1997). Infection by parvovirus B19 during pregnancy: a review. Obstet Gynecol Surv 52:254 –259. Shapiro, L. (1965). The numbered diseases: first through sixth. JAMA 194:210. Skeikh, A. U., Ernest, J. M., & O’Shea, M. (1992). Long term outcome in fetal hydrops from parvovirus B19 infection. Am J Obstet Gynecol 167:337–341.
Case Report
Infection by human parvovirus B19: “gloves and socks” papular purpuric syndrome Prudencio Martı´nez–Martı´neza,*, Angel Maran˜o´nb a
Department of Microbiology, University Hospital of Valladolid, Valladolid, Spain Department of Internal Medicine, University Hospital of Valladolid, Valladolid, Spain
b
Received 22 February 1999; received in revised form 3 November 1999
Abstract Human parvovirus B19 is the cause of erythema infectiosum a benign and self-limited infection, but sometimes the virus causes an acute and self-limiting dermatosis. It consists of a edema and erythema of the hands and feet in a gloves and sock distribution and is associated with oral lesions and fever. We report a case of a “gloves and socks” infection by human parvovirus B19. © 2000 Elsevier Science Inc. All rights reserved.
1. Introduction Human parvovirus B19 has been identified as the cause of erythema infectiosum also known as fifth disease (Shapiro, 1965; Anderson et al., 1983). The virus affects mainly to school-aged children, usually among these it causes outbreaks characterized by the typical rash of the erythema infectiosum (Gillespie et al., 1990). It has also been associated with arthralgia (Balkhy et al. 1998), aplastic crisis (Carper and Kurtzman, 1996) and hidrops and death fetal (Levy et al., 1997). This report describes an infection by human parvovirus B19 “gloves and socks” papular purpuric syndrome.
2. Case report A 27-year-old male presented to University Hospital of Valladolid with a painful, pruriginous, purplish vasculitis of sudden onset, 48-h-old, affecting his extremities. It was highly localized, more prominent on the palms than on the backs of his hands and more prominent on the tops than on the soles of his feet, and lack-like in appearance. Purplish vasculitic lesions were also observed where his thighs met his trunk, in his armpits and on his chest, distributed over * Corresponding author. Tel.: ⫹696-400-921; fax: ⫹91-358-1142. E-mail address: [email protected]. (P. Martı´nez–Martı´nez).
the decubitus zone. Accompanying this vasculitis, the patient reported chills, asthenia, general malaise, pain upon eating, and a fever of 39.8°C that did not remit when he took antipyretics (acetaminophen). He showed no meningeal signs, but he did exhibit painful rolling retroarticular, submaxillary, bilateral, and supraclavicular laterocervical adenopathy, although it was more intense and painful on the right-hand side. The patient, a heterosexual with a steady sexual partner at that time, a car salesman, and bouncer by profession who was also studying law, reported having received no insect bites nor having traveled abroad in recent months. Twenty-four hours after hospitalization, the oral mucus displayed an enanthema on the hard palate, vesicular aphthoid lesions on the soft palate and pharynx, as well as edema and vesiculation on the lips and around the mouth that eventually prevented the patient from opening his mouth and taking solid foods. From among the analytic data taken on serum biochemistry, blood count, hemostasis, urine sediment, lymphocyte population, blood cultures, pharyngeal smear, urine culture, and ASLO taken at the patient’s emergency registration, the only item proving abnormal was the patient’s lymphocyte percentage (6.1%), which two days later rose to 14.6% whereas the leukocyte total fell to 4410 (5670 leukocytes at hospitalization). The number of platelets did the same, settling at 120 000 compared to the 152 000 present at first. A serological study for the following bacteria and viruses was also run: Treponema pallidum, rickettsias, HIV, HCV,
0732-8893/00/$ – see front matter © 2000 Elsevier Science Inc. All rights reserved. PII: S 0 7 3 2 - 8 8 9 3 ( 0 0 ) 0 0 1 3 3 - 9
210
P. Martı´nez–Martı´nez / Diagnostic Microbiology and Infectious Disease 36 (2000) 209 –210
HBV, HAV, CMV, Epstein–Barr, Coxsackie A and B, ECHO virus, human parvovirus B19, varicella-zoster virus, rubella, and measles. All were nondiagnostic except the human parvovirus B19. The detection in serum of IgM and IgG antibodies for human parvovirus B19 were realized with a sandwich enzyme immunoassay (Parvovirus B19 Enzyme Immunoassay for IgM and IgG, respectively, Biotrin, France). In the first serum (three days after on set of illness) was detected a low positive IgM (0.650 Optical Density, OD), whereas in the second serum taken nine days after on set of illness was detected a high positive IgM (1.667 OD). The IgG displayed a seroconversion (1° serum: 0.132 OD; 2° serum: 0.414 OD). The pre- and post-samples for IgM and IgG were tested at the same time. Also, in the first serum was detected some slight reactivity for the HIV p24 antigen (70 pg/ml) that was not confirmed by neutralization. The biopsy showed a small-vessel leukocytoclastic vasculitis. Antipyretic (acetaminophen) and broad-spectrum antibiotic (erythromycin 500 mg/8 h) treatment was applied for three days, and the lesions remitted in the days thereafter. The patient remained fever-free as of the fourth day of hospitalization.
3. Discussion The “gloves and socks” papular purpuric syndrome was described by Harms et al. (1990). Nevertheless, it was Bagot and Revuz (1991) who related the existence of a primary human parvovirus B19 infection with this syndrome. At all events, not all cases of this syndrome are due to human parvovirus B19 (Hjorther and Hansen, 1996), and therefore we had to run a differential diagnostic with other infectious agents how bacterial infections such as syphilis (secondary syphilis), and rickettsial diseases (Rickettsia conorii), although he recalled no tick bites or rural habits. Traveling abroad would have obliged us to test for erhlichia infection as well (Fisbein et al., 1994). The negative pharynx culture for group-A streptococcus allowed us to rule out scarlet fever. Having eliminated the bacterial agents, we had to search among the viral agents, especially cytomegalovirus, Epstein–Barr, HBV, Coxsackie A and B, and ECHO virus (Cherry, 1993). Lastly, there are complaints of noninfectious origin that must be considered, such as Kawasaki disease, lupus erythematosus, reactions to medicines and environmental allergies, and secondary hives after the administration of heroin. The laboratory results confirmed the diagnosis of acute human parvovirus B19 infection (IgM-EIA). This fact was reinforced by the detection of a seroconversion for IgGEIA. IgM is usually detected within three days after the onset of the symptoms of viremia, and IgG several days
later. After a month, IgM levels begin to decline. IgG levels vary significantly from patient to patient, so whether it grows or not can probably not be used to rule out a recent infection (Skeikh et al., 1992). In immunocompromised patients’ serum, immunoglobulins (IgM and IgG) may be absent or present intermittently, so the use of hybridization and Polymerase Chain Reaction techniques is recommended for a definitive diagnosis. The patient’s jobs and activities could have favored his infection due to his contact with such large numbers of potentially infectious young individuals. In fact, school cafeteria workers and the personnel of nurseries and schools seem to display a higher risk to acquire this infection. This may occur through fomites (e.g. plates and eating utensils), direct contact or large-particle aerosols belonging to students (Gillespie, 1990). In general, human parvovirus B19 infection in immunocompetent individuals tends to cause a benign, self-limited infection that requires no more than supportive treatment. Solely on very rare occasions can a “gloves and socks” case similar to this be observed. In fact, only about 29 cases have been published to date.
References Anderson, M. J., Jones, S. E., Fisher-Hoch, S. P., Lewis, E., Hall, S. M., Bartlett, C. L. R., Cohen, B. J., Mortimer, P. P., & Pereira, M. S. (1983). Human parvovirus: the cause of erythema infectiosum (fifth disease)? Lancet 1:1378. Bagot, M., & Revuz, J. (1991). Papular-purpuric “gloves and socks” syndrome: primary infection with parvovirus B19? J Am Acad Dermatol 25:341. Balkhy, H. H., Sabella, C., & Goldfarb, J. (1998). Parvovirus: a review. Bull Rheum Dis 47:4 –9. Carper, E., & Kurtzman, G. J. (1996). Human parvovirus B19 infection. Curr Opin Hematol 3:111–117. Cherry, J. D. (1993). Contemporary infectious exanthems. CID 16:197– 199. Fisbein, D. B., Dawson, J. E., & Robinson, L. E. (1994). Human ehrlichiosis in the United States. Ann Intern Med 120:736 –743. 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: 2061–2065. Harms, M., Feldmann, & Saurat, J. H. (1990). Papular-purpuric “gloves and socks” syndrome. J Am Acad Dermatol 23:850 – 854. Hjorther, A. B., & Hansen, E. R. (1996). “Glove-sock” syndrome. A new disease entity. Ugeskrift for Laeger 158:1380 –1381. Levy, R., Weissman, A., Blomberg, G., & Hagay, Z. J. (1997). Infection by parvovirus B19 during pregnancy: a review. Obstet Gynecol Surv 52:254 –259. Shapiro, L. (1965). The numbered diseases: first through sixth. JAMA 194:210. Skeikh, A. U., Ernest, J. M., & O’Shea, M. (1992). Long term outcome in fetal hydrops from parvovirus B19 infection. Am J Obstet Gynecol 167:337–341.