FACT SHEET: Fifth Disease (also known as “erythema infectiosum” and “slapped-cheek disease”; caused by human parvovirus B19, which is also known as erythrovirus B19; the virus targets rapidly growing erythroid progenitor cells; in young adults, the virus may manifest as “gloves and socks syndrome”)
Fifth disease received its name because it was fifth in a list of historical classifications of common skin rash illnesses in children.
Is the initiation of non-invasive dental hygiene procedures* contra-indicated?
- Yes, if the patient/client is contagious and/or has significant morbidity. Limiting exposure to a potentially infectious patient/client is particularly important if you, the dental hygienist, may be pregnant and not immune to parvovirus B19.
Is medical consult advised?
- Yes, if the diagnosis is uncertain (including differentiation from rubella, scarlet fever, and erythema multiforme) and/or the patient/client is not already under medical care. If it is necessary to see a physician, the patient/client should call first to minimize exposure to others.
Is the initiation of invasive dental hygiene procedures contra-indicated?**
- Yes, if the patient/client is contagious and/or has significant morbidity.
Is medical consult advised?
- See above.
Is medical clearance required?
Is antibiotic prophylaxis required?
Is postponing treatment advised?
- Yes, during the period of communicability (see below).
Oral management implications
- Mode of transmission is primarily through personal contact, via aerosols, respiratory secretions (including sputum and nasal mucus), or saliva droplets when an infected person sneezes or coughs. Transmission can also occur transplacentally from mother to fetus, and parenterally through transfusion of blood and blood products (for which risk is reduced in Canada, because of viral inactivation procedures used for plasma-derived products).
- More common in children than in adults, fifth disease occurs sporadically or in epidemics. In persons with rash illness alone, the period of communicability is greatest before the onset of rash (i.e., when there was just “a cold”), with transmission less likely thereafter. However, children with the disease should be considered infectious from a few days before the onset of rash until the rash has faded, usually a span of one week to 10 days. For some persons, it may be safe to be around others and return to work once the rash appears. However, persons with aplastic crisis may be infectious for longer, and immunosuppressed people with chronic infection and severe anemia can be infectious for months to years.
- It takes from 4 to 20 days after exposure to a person with fifth disease for a non-immune individual to develop a rash or, in susceptible persons (i.e., those with hemolytic anemia, such as sickle cell disease), symptoms of an aplastic crisis. Rash is often atypical or absent in adults. 20% to 25% of children and adults newly infected with parvovirus B19 do not have any symptoms.
- Once recovery occurs from fifth disease, life-long immunity is generally conferred.
- If you, the dental hygienist, are pregnant (or are immunosuppressed or have sickle cell disease or thalassemia) and have never had fifth disease, you should avoid contact with persons with contagious erythema infectiosum. If you are exposed to parvovirus B19 virus and are non-immune, contact your physician. Exposed pregnant women can be offered B19 antibody testing to determine susceptibility and to assist with counseling with regard to risk to their fetuses.
- There is no vaccine or medicine that is available to prevent parvovirus B19 infection.
- All health care providers and patients/clients should follow strict infection control practices to prevent parvovirus B19 from spreading in the workplace.
Related signs and symptoms
- Fifth disease usually presents in children as a mild illness with red rash. Mild constitutional symptoms — such as low-grade fever, runny nose, headache, and nausea — often precede onset of rash by several days. A striking redness of the face (“slapped cheek” appearance) is the most recognized feature of the illness; this is more common in children than adults. Some people may additionally develop a lace-like rash on the trunk or extremities several days later. This second rash may be itchy, especially on the soles of the feet and palms of the hands. This rash can vary in intensity and may come and go for several weeks, particularly upon exposure to sunlight or heat (e.g., bathing). As the second rash fades, it may look particularly lacy.
- In adults, rash is often atypical or absent. While 25% or more of parvovirus B19 infections may be asymptomatic, arthralgias or arthritis (polyarthropathy syndrome) lasting days to even years may occur. Hands, feet, and knees are most commonly affected, with joint pain and swelling usually resolving in 1 to 3 weeks. In North America, 50% to 80% of adults have serological evidence of past infection, depending on age and location.
- In young adults, parvovirus B19 infection may present as symmetric, painful erythema and edema of the feet and hands known as “gloves and socks” syndrome. There is a sharp demarcation of the papular, purpuric rash at the wrists and ankles, although other areas may also be involved. Patients/clients may experience fever, arthralgia, or both. Signs and symptoms usually resolve within 1 to 3 weeks.
- While severe complications of parvovirus B19 infection are unusual, the body may temporarily stop making new red blood cells. This can lead to transient aplastic crisis in persons with anemia that requires increased red blood cell production (e.g., sickle cell disease and thalassemia). Persons who are immunosuppressed may develop severe, chronic anemia.
- Most pregnant women who are not immune do not have serious complications after they are exposed to others with fifth disease. They usually have only mild illness, and their fetuses usually do not have any problems. However, sometimes a fetus will develop severe anemia, which may be accompanied by thrombocytopenia (low platelet count). Infection in the first trimester may result in fetal loss or miscarriage. Infection in the second and third trimesters may result in fetal anemia, myocarditis, high output cardiac failure, hydrops fetalis (severe edema), and stillbirth. Fetal death occurs in up to 10% of infected fetuses. However, miscarriage happens in fewer than 5% of all pregnant women with parvovirus B19 infection, and this is usually confined to the first half of pregnancy.
- Several diseases (e.g., systemic vasculitis, autoimmune hepatitis, myocarditis, and rheumatoid arthritis) have been reported to occur in association with erythema infectiosum, although causality has not been established. Seizures, meningitis, encephalopathy, and dilated cardiomyopathy are other putative complications of parvovirus B19 infection.
References and sources of more detailed information
- MacDonald NE, O’Brien SF, Delage G. Transfusion and risk of infection in Canada: Update 2012. Paediatr Child Health
- Public Health Agency of Canada http://www.phac-aspc.gc.ca/lab-bio/res/psds-ftss/parvovirus-eng.php
- Centers for Disease Control and Prevention http://www.cdc.gov/parvovirusB19/fifth-disease.html
- Medscape https://emedicine.medscape.com/article/961063-treatment (Parvovirus B19 Infection Treatment & Management)
- Heymann D (ed.). Control of Communicable Disease Manual (20th edition). Baltimore: American Public Health Association; 2015.