Pharmacists, have you ever been completely baffled with a case or set of symptoms in practice? This is not as rare as you think. This is exactly what happened to me whilst I was a newly qualified working in a busy Community Pharmacy in Hilton, which is within the
Derbyshire area. In the space of one day, I had 3-4 walk in enquiries about treatment for children who have acquired ‘Slapped Cheek’ from attending their pre-school. But what exactly is this mystery syndrome? With it being a topic which is rarely covered in the
Pharmacy Schools, The Pharmacist Cooperative has decided to launch a CPD training article on the syndrome known as ‘Slapped Cheek’.

It is more common in children than in adults [5].

Preschoolers or school age children are often affected. The spread of this virus thrives in the spring and summer months of the year [3].
The syndrome is often much milder in adults [6].
The Parvovirus B19 virus infects humans only. Animals are not hosts [6].

Notes – Veterinary Considerations
Pet dogs and cats can be immunised against Parvovirus. However these are animal parvoviruses which are different from Parvovirus B19 [7, 8]. Please see Veterinary Notes at the end of the article for more detail.

Transmission (Spread of Infection)
It is mainly spread through droplets from respiratory secretions such as saliva, sputum or nasal mucus [1].
It can also be transmitted via blood transfusions, bone marrow transplants and other blood products.
A pregnant mother can also transmit the infection via the placenta to her unborn child [5,7 & 8]

Incubation Period

Definitions

The incubation period for Slapped Cheek Syndrome is 4-20 days before the rash appears. By the time the rash develops it is usually no longer infectious [7,8]. Humans only have Slapped Cheek Syndrome once in a life time. This is because antibodies are made during the infection which protects the host from future infections from the same virus [7,8].

Differential Diagnosis
Many viral skin rashes or eruptions can be included in the differential diagnosis, namely measles, rubella, roseola and scarlet fever [1].

Diagnosis
It is often diagnosed just by the presentation of the classical ‘Slapped Cheek’ rash on a patient’s face [5, 7 & 8]. Blood work can be performed if necessary to test for specific antibodies. The test is a non-routine one; it is performed in special circumstances and it can
identify if a patient was recently infected with Parvovirus B191, [8]. It can also help determine if a patient is susceptible or possibly immune to the virus. This blood test is particularly useful and is often performed on pregnant women who may have been exposed to
parvovirus B19 and /or are suspected to have the condition1, [7 & 8].

Symptoms

Second Stage – Some people may develop a second rash a few days later on different parts of the body, namely the chest, back, arms, legs and feet [8].

This second rash has a different appearance; it is lighter in colour and is raised and itchy. Itchiness can be particularly troublesome on the soles of the feet. It can be of a lacy nature (a pink lace pattern / net -like look can be observed) [4].

Duration – Classically appears 1-4 days after the cheek rash. The second rash usually fades within 2 weeks 2, 10. Sometimes it can last up to a month or more, with the rash fading and returning several times for several weeks [7,8 &12].

Other symptoms
High temperature
Headache
Sore throat
Runny nose [2,5] Joint pain; it is more common in adults, particularly women [1] Stiffness; it is more common in adults [7, 8] Lethargy
Polyarthropathy syndrome; It is more common in adults, particularly women [5]

Vulnerable Patients
The symptoms of Fifth Disease are not usually life threatening and dangerous complications are usually rare [4].
However, patients groups who can be more severely affected by the syndrome include:

Vulnerable patients such as –
Pregnant women [2].
Patients with sickle cell anaemia, chronic haemolytic disease or thalassaemia;
Infection by Parvovirus destroys reticulocytes. There is a risk of aplastic crisis and severe anaemia if this patient group contracts              Slapped Cheek Syndrome [1].
Immunocompromised patients e.g. patients with Leukaemia, HIV infection [1, 12].
Diabetic patients [2].
Patients who have recently had an organ transplant [1, 12].
Patients who take medications which weaken the immune system [1,2].
For example

Immunosuppressants e.g. Tacrolimus, Ciclosporin, Mycophenolate Mofetil [13, 14].
Corticosteroids e.g. Hydrocortisone, Dexamethasone, Fludrocortisone [15].
TNF inhibitors e.g. Adalimumab, Infliximab, Etanercept [16].
Anti – cancer medications and chemotherapy drugs e.g. – Methotrexate, Flourouracil, Cisplatin [16, 17].
Fingolimod [18].
DMARDs e.g. Sulfasalazine (commonly cause leucopenia) [19].

Any vulnerable patients suspected of having contracted Parvovirus B19 should be referred to their GP or a medical doctor for further investigations. These patients are at risk of complications and often laboratory investigations will be arranged to confirm the diagnosis
and to check the full blood count, including the reticulocyte count [1, 2 & 20]. A special blood test to detect antibodies to the virus [3] can be performed; the presence of specific human Parvovirus B19 igM antibody can confirm acute infection on serology [1,3]. This igM antibody is usually found within 7-10 days of virus exposure [1,3 & 20].

Treatment

The disease process is typically mild and self-limiting. Healthy children and adults usually recover completely without medical intervention [2,7-8]. No antiviral therapy exists for Parvovirus B19 infection. Therefore the symptoms of the infection are typically treated rather than the infection itself [2-3 & 6-7].

 

Treatment Snapshot

Troublesome symptoms include pain, fever, stiffness, headache, swelling and itching [2-3]. Simple analgesia such as Paracetamol or Ibuprofen at the correct dose can be used to treat the high temperature, pain, headaches and joint pain in appropriate child and adult
patients [2-3].

In rare cases of prolonged joint pain and swelling, other Non-Steroidal Anti-Inflammatories (NSAIDs) can be considered e.g. naproxen in appropriate adult patients. Chronic Parvovirus Arthritis can benefit from drugs like hydroxychloroquine [2-3].

Moisturisers such as E45, Cetraben and Aveeno Cream can be used generously on appropriate areas of itchy skin and rashes. A soothing calamine lotion can also be tried to tackle this problem [2-3, 20].

Patients can speak to a pharmacist or their doctor if the itching skin is particularly troublesome as these healthcare professionals could recommend an antihistamine where appropriate. This is useful for patients where skin itching keeps them up at night [2-3, 7-8 & 20].

Prevention and Self-care
Plenty of rest
Staying hydrated
Eating a healthy, balanced diet
Altering their activities to help alleviate particular symptoms
Using moisturiser liberally if needed on the rash and itchy skin
Good hygiene e.g. hand washing can prevent transmission [2-3 & 7-8].

Pregnancy
Parvovirus can be transmitted from mother to the fetus via the placenta [2,21]. Often, most pregnant women are immune to the infection already as they may have contracted the disease in childhood themselves and hence will have antibodies for Erythema Infectiosum [21]. A good proportion of pregnant women who acquire the infection in pregnancy will still have healthy babies [2,21].
Fifth disease in pregnant women is not usually life threatening. However it does carry a burden of heightened risk of complications to the mother and baby. Maternal symptoms of fifth disease can be short-lived. But subsequent fetal complications can be lengthy and risky [21-23].

Infection in pregnancy is the most dangerous and carries the most risk between 4 and 20 weeks of pregnancy [21].

Complications which can arise include-
Miscarriage (spontaneous abortion) [1,2] Intrauterine death
Stillbirth
Congenital anomalies (although the virus is not a significant teratogen)
Fetal Anaemia
Hydrops Fetalis [1, 22] Neonatal Complications including hepatic insufficiency, myocarditis and central nervous system abnormalities [1, 21, 22]. Pregnant patients suspected of being exposed to Parvovirus should report to their doctor or healthcare professionals responsible for their antenatal care immediately. Likewise, pregnant patients who are suspected of having contracted the disease should also do the
same [21-23]. Blood work and laboratory tests may be performed to confirm the diagnosis. Additionally ultrasounds may be performed [23].

If a mother is confirmed to have the infection, close monitoring of the patient is required for their disease presentation and also for any fetal complications21-23. There is no specific treatment for the infection in pregnant women. Pain and fever can be treated with
paracetamol and is safe in pregnancy [23].

Notes- Rubella Status
Rubella can be mistaken for Parvovirus and vice versa, particularly in pregnant women. Therefore it is wise to perform a blood test to check the patient’s Rubella status, particularly if there is no past record of rubella testing or MMR immunisation [21]. It is important for clinicians and healthcare professionals to be aware of possible misdiagnosis and is sensible for the patient to avoid contact with other pregnant women while any rash is present, until the Rubella and Parvovirus status is known [20, 23].

Veterinary Notes

Pet dogs and cats can be immunised against parvovirus. However these are animal parvoviruses which are different from Parvovirus B19 [7-8]. Species specific parvoviral infections cause similar clinical syndromes, known as Parvovirus in dogs and Feline Panleukopenia in cats [24]. The young, old and unvaccinated animals are most at risk [24-25].

Breeds most at risk:
Dogs – Labrador Retrievers, Pit Bulls, Rottweilers, Doberman Pinschers  [24 & 26].
Cats – Kittens are particularly susceptible [25].

Clinical signs in Cats and Dogs –
Vomiting and watery diarrhoea (often of haemorrhagic nature)

Fatigue and lethargy
Fever
Reduced appetite and/or Inability to eat or drink [24-25]

Diagnosis: Based on general history (e.g. exposure to other animals), symptoms, supportive blood work findings and a Positive faecal snap ELISA test [24, 26-27].

 

Author of this CPD Training Article

Priya Ved MRPharmS.
Locum Pharmacist & Freelance Pharmacy Writer.
Member of The Royal Pharmaceutical Society and The Pharmacy Defence
Association.
Qualified in British Sign Language up to Level 1.

 

References
1. Kostolanksky, Sean and Waymack, James, 2019. Erythema Infectiosum (Fifth Disease). StatPearls [Internet]. Treasure Island. StatPearls Publishing. Accessed Dec 2019. URL: https://www.ncbi.nlm.nih.gov/books/NBK513309/

2. The National Health Service Online. Health A to Z: Slapped Cheek Syndrome. 2018. [Internet]. Accessed Nov-Dec 2019.
URL: https://www.nhs.uk/conditions/slapped-cheek-syndrome/

3. The Arthritis Foundation. Fifth Disease; what is Fifth Disease. 2019. [Internet]. Accessed Oct-Dec 2019.
URL: https://www.arthritis.org/about-arthritis/types/fifth-disease/

4. The Royal Children’s Hospital Melbourne. Kid’s Health info; Slapped Cheek (fifth disease). 2018 [Internet]. Accessed Oct-Dec 2019.
URL: https://www.rch.org.au/kidsinfo/fact_sheets/Slapped_cheek_fifth_disease/

5. Centre for Disease Control and Prevention. Parvovirus B19 and Fifth Disease. 2019. [Internet]. Accessed Oct-Dec 2019. URL: https://www.cdc.gov/parvovirusb19/fifth-disease.html

6. The Centre for Health Protection, Department of Health, The Government of the Hong Kong Special Administrative Region. Fifth Disease. 2019. [Internet]. Accessed Oct-Dec 2019. URL: https://www.chp.gov.hk/en/healthtopics/content/24/22.html .

7. Patient Info Website. Slapped Cheek Disease. 2016. [Internet]. Accessed Oct-Dec 2019.
URL: https://patient.info/childrens-health/slapped-cheek-disease-leaflet

8. Patient Info Website. Parvovirus Infection. 2016. [Internet]. Accessed Oct-Dec 2019.
URL: https://patient.info/doctor/parvovirus-infection

9. Baby Information. Slapped Cheek Syndrome. 2017. [Internet]. Accessed Dec 2019. URL: https://www.babyinfo.com.au/newborns-and-infants/slapped-cheek-syndrome

10. NHS Information Scotland. Slapped Cheek Syndrome. 2019. [Internet]. Accessed Dec 2019. URL: https://www.nhsinform.scot/illnesses-and-conditions/infections-andpoisoning/slapped-cheek-syndrome

11. Iris Health. Slapped Cheek Disease. 2019. [Internet]. Accessed Nov-Dec 2019. URL: http://www.irishhealth.com/article.html?con=653

12. Kopp, Jeffrey and Waldman, Meryl, 2007. Parvovirus B19 and the Kidney. The Clinical Journal of American Society of Nephrology. [Internet]. Accessed Dec 2019. URL: https://cjasn.asnjournals.org/content/2/Supplement_1/S47

13. The National Kidney Foundation. A to Z Health Guide: Immunosuppressants. 2019. [Internet]. Accessed Nov-Dec 2019.
URL: https://www.kidney.org/atoz/content/immuno

14. The British National Formulary. Immune Response; Immunosurpressant therapy. 2019. [Internet]. Accessed Oct-Dec 2019.
URL: https://bnf.nice.org.uk/treatment-summary/immune-response.html

15. The British National Formulary. Corticosteroids, General Use. 2019. [Internet]. Accessed Oct-Dec 2019.
URL: https://bnf.nice.org.uk/treatment-summary/corticosteroids-general-use.html

16. The British National Formulary. Rheumatic Disease, Suppressing Drugs. 2019. [Internet]. Accessed Oct-Dec 2019.
URL: https://bnf.nice.org.uk/treatment-summary/corticosteroids-general-use.html

17. Macmillan Cancer Support. Chemotherapy Drugs and combination regimens. 2019. [Internet. Accessed Dec 2019.
URL: https://www.macmillan.org.uk/information-andsupport/treating/chemotherapy/drugs-and-combination-regimens

18. The British National Formulary. Fingolimod Drug Monograph. 2019. [Internet]. Accessed Oct-Dec 2019.
URL: https://bnf.nice.org.uk/drug/fingolimod.html

19. The British National Formulary. Sulfasalazine Drug Monograph. 2019. [Internet]. Accessed Oct-Dec 2019.
URL: https://bnf.nice.org.uk/drug/fingolimod.html

20. National Institute for Health and Care Excellence. Parvovirus B19 Infection. 2017. [Internet]. Accessed Oct-Dec 2019.
URL: https://cks.nice.org.uk/parvovirus-b19-infection#!scenario

21. The National Health Institute North Bristol Trust. Parvovirus B19. 2017. [Internet]. Accessed Nov-Dec 2019.
URL: https://www.nbt.nhs.uk/maternity-services/pregnancy/routine-screeningtests-scans/parvovirus-b19

22. Koren, Gideon. Garcia-Bournissen, Facundo. Klieger-Grossman, Chagit. Staroselsky, Arthur. Exposure to Fifth Disease in Pregnancy, 2009. The Official Publication of The College of Family Physicians of Canada. [Internet]. Accessed Oct-Dec 2019.
URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2793222/

23. University Hospital of North Staffordshire NHS Trust. Patient Information; Parvovirus in Pregnancy. 2017. [Internet]. Accessed Nov-Dec 2019. URL: http://www.uhnm.nhs.uk/OurServices/Maternity/PublishingImages/Pages/Patient-information-leaflets/Parvovirus%20in%20pregnancy.pdf

24. The Metropolitan Veterinary Associates. Canine Parvoviral Infection and Feline Panleukopenia.

2019. [Internet]. Accessed Dec 2019.
URL: https://metro-vet.com/references/canine-parvo-viral-infection-and-felinepanleukopenia/

25. The Cat’s Protection League. Feline Parvovirus (FPV). 2019. [Internet]. Accessed Nov-Dec 2019.URL: https://www.cats.org.uk/media/1034/vg05_feline_parvovirus_-fpv.pdf

26. Norkus, Christopher, 2018. Veterinary Technician’s Manual for Small Animal

Emergency and Critical Care. Second Edition. Canine Parvovirus. John Wiley and Sons.
[Internet]. Accessed Dec 2019. URL:
https://books.google.co.uk/books?id=rXFuDwAAQBAJ&pg=PT377&lpg=PT377&dq=la
b+retrievers+rottweilers+pitbull+doberman+parvovirus&source=bl&ots=uDgc3bYRYQ
&sig=ACfU3U2K_P4OBE6MY7RG887g0mREvCF8Rg&hl=en&sa=X&ved=2ahUKEwihwZ
et9d7mAhXYQxUIHdCxAGwQ6AEwF3oECAgQAQ#v=onepage&q=lab%20retrievers%2
0rottweilers%20pitbull%20doberman%20parvovirus&f=false

27. Groen, A. Juntti, N et al. Evaluation of enzyme-linked immunosorbent assays based on monoclonal antibodies for the serology and antigen detection in canine parvovirus infections, 1990. National Institute of Public Health and Environmental Protection,
Bilthoven, The Netherlands.[Internet]. Accessed Nov-Dec 2019. URL: https://www.ncbi.nlm.nih.gov/pubmed/2157312

28. The British National Formulary. Aspirin Drug Monograph. 2019. [Internet]. Accessed Oct-Dec 2019.
URL: https://bnf.nice.org.uk/drug/aspirin.html#contraIndications

29. Mount Nittany Health. When Your Child has Fifth Disease. 2017. [Internet]. Accessed Jan 2020.
URL: https://www.mountnittany.org/articles/healthsheets/7334

 

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