What are the signs and symptoms of parvovirus B19 (B19V) infection?

Updated: Oct 11, 2019
  • Author: David J Cennimo, MD, FAAP, FACP, FIDSA, AAHIVS; Chief Editor: Russell W Steele, MD  more...
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Common symptoms of parvovirus B19 (B19V) infection include a mild nonspecific prodromal illness that may consist of fever (15-30% of patients), malaise, headache, myalgia, nausea, and rhinorrhea; typically beginning 5-7 days after initial infection. [8, 28] These symptoms correspond to the initial viremia and dissipate in 2-3 days. [5] Approximately 1 week later, a bright red macular exanthem appears on the cheeks and is often associated with circumoral pallor. [9, 5] A diffuse maculopapular rash can appear 1-4 days later and fades to a lacy erythematous rash, which may be pruritic and may spread gradually toward the distal extremities. Most seropositive patients have no history of this classic biphasic illness. The clinical symptoms widely vary, and the classic "slapped cheek" rash is much more common in young children. [8]  More recently, parvovirus B19 has been recognized as a cause of atypical rash illness in adults, [29]  as well as a host of less common manifestations. [30]  

  • The cause of parvovirus B19 rash is believed to be immunologically mediated, and the rash corresponds to the appearance of immunoglobulin M (IgM) in the serum. This signals the clearance of viremia. Recurrence of the rash (lasting for weeks or more) may be provoked by sunlight, stress, or exercise and does not indicate relapsed infection. [2, 5]

  • Alternatively, parvovirus B19 infection may manifest with purpuric rash, erythema multiforme, or pruritus of the soles of the feet. Parvovirus B19 may cause a papular-purpuric "gloves-and-socks" syndrome (PPGSS), which manifests as an erythematous exanthem of the hands and feet with a distinct margin at the wrist and ankle joints. It is mainly seen in young adults and initially presents with painful erythema and induration of the hands and feet. Less commonly, the penis, vulva, thighs, cheeks, and elbows may be involved. This syndrome occurs exclusively with parvovirus B19 infection and is an uncommon manifestation. The skin changes may progress to petechia, purpura, and bulla with skin sloughing. PPGSS usually resolves in 1-3 weeks without scaring. [5, 6, 31, 32]

  • Transient small joint arthropathy may be the main clinical presentation of parvovirus B19 in adults. Most have some joint pain, but few progress to frank arthritis. In general, the timing of joint symptoms coincide with the expected onset of rash in children. Arthritis usually improves in 1-3 weeks but may persist for months. Parvovirus B19 infection is not associated with chronic degenerative arthritis. [8, 2, 6] Less than 10% of children experience arthropathy; however, in those who do, the knees are most commonly involved. [9]

  • Patients with severe anemia due to transient aplastic crisis (TAC) may present with pallor, fatigue, or signs of an aplastic crisis. Underlying hemoglobinopathies should be sought in these patients. Patients with thrombocytopenia may exhibit bruising. [8, 11, 2, 13]

  • Rarely, parvovirus B19 infection manifests as myocarditis, vasculitis, glomerulonephritis, or encephalitis. B19V infection has been reported in association with idiopathic thrombocytopenia purpura, Henoch-Schönlein purpura, and pseudoappendicitis. It has also been reported to precipitate hemophagocytic syndrome. [5, 8, 2, 11] In rare cases, parvovirus B19 has been implicated in fatal myocarditis in transplant patients, [17] and has been implicated as a cause of endothelial dysfunction in patients with diastolic dysfunction. [34]

  • Parvovirus B19 infection in pregnant women may result in hydrops fetalis, particularly when infection occurs before 20 weeks' gestation. In the United States, the most common etiology of hydrops fetalis is parvovirus B19 infection. [25, 9, 8, 22]

  • Neurologic manifestations associated with parvovirus B19 infection widely vary. [5] Peripheral nervous system involvement such as neuropathy may be seen more frequently in older immunocompetent individuals. CNS involvement, including meningitis, encephalitis, and seizure, has been demonstrated in younger children and immunocompromised patients. [35]

  • Many individuals may experience asymptomatic or unrecognized infection.

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