To the Editors: Human parvovirus B19 (B19) infection shows a wide spectrum of cutaneous manifestations and systemic involvements, especially in adults. Acute hepatitis and hepatic disorders are rare, however, and there are only 2 reports of B19 infection associated with acute hepatitis in adults in the English literature.1,2 To our knowledge, the case reported in this article is the first case of B19 infection associated with acute hepatitis in an infant. A 9-month-old female infant presented at our hospital with high-grade intermittent fever (39°C) for 6 days, associated with erythematous maculopapular nonpruritic rash. Her parents denied any drug intake or exposure to children or adults with exanthematous diseases. Erythematous maculopapular rashes were present over the entire body, excluding the palms and soles. The rash first appeared on the face within 12 hours of the onset of fever, and later spread to the trunks and limbs. After 7 to 10 days, a central clearing appeared in the rash that had a lace-like or reticular appearance especially on the cheeks, which looked like “slapped-cheek.” There was no hepatosplenomegaly or palpable lymph nodes. As the symptoms and signs suggested erythema infectiosum, we asked for the consent of the parents of the patient to perform further evaluations to determine the causative agent. We conducted normal tests such as a full blood count, measurement of the prothrombin time and the muscle enzymes, and urinalysis. The serum alanine aminotransferase level was 4745 U/L (normal level: 10–35), the aspartate aminotransferase level was 3428 U/L (normal level: 5–38), and the lactate dehydrogenase level was 825 U/L (normal level: 106–211). The serologic tests for cytomegalovirus, Epstein-Barr virus, herpes simplex virus, and hepatitis A, B, C, and E viruses were all negative. Enzyme-linked immunosorbent assay revealed anti-B19 IgM 5.77 (normal level: <0.8) and IgG 0.61 (normal level: <0.8) antibodies. Using the polymerase chain reaction (Chung-Ang University Hospital Laboratory, Seoul, Korea), the serum was positive for B19. Based on these clinical features and investigations, the patient was finally diagnosed to have erythema infectiosum with acute hepatitis. The patient was treated with antipyretics and rest. The skin eruption cleared in 10 days without desquamation, and the aminotransferase values became normal within 14 days. Three weeks later, the anti-B19 enzyme-linked immunosorbent assay had changed to IgM 0.41 (normal level: <0.8) and IgG 9.40 (normal level: <0.8). B19 infection has a worldwide distribution, with school outbreaks in late winter and early spring. It affects primarily the 4- to 10-year age group. Although the disease is self-limiting, systemic features with B19 infection make its diagnosis important.3 Systemic features are severe in adults, including arthralgia with synovitis and rarer manifestations such as aplastic crisis in patients with chronic hemolytic anemia, bone marrow failure in immunocompromised hosts, a transient febrile myasthenia-like syndrome, myositis, and acute heart failure. These occur rarely in infants.4 B19 infection is associated with a wide spectrum of clinical manifestations, including erythema infectiosum, rubilliform rashes, the Gianotti-Crosti syndrome, Henoch-Schönlein purpura, the papular purpuric gloves-and-socks syndrome, and erythema multiforme. The best known of these is erythema infectiosum, or fifth disease, which classically occurs with childhood infections.3,4 Erythema infectiosum is characterized by confluent erythematous and edematous patches or plaques on the cheeks, which spare the nasal bridge and periorbital regions. The rash spreads to the trunk and extensor extremities, which undergo patchy clearing that results in a lace-like reticular pattern. Occasionally, mild prodromal symptoms precede the rash, which include low-grade fever, headache, pharyngitis, malaise, myalgias, nausea, diarrhea, and joint pain.5 To our knowledge, there are only 2 reports of B19 infection, both in adults, associated with acute hepatitis in the English literature.1,2 We documented a case of erythema infectiosum with acute hepatitis in a 9-month-old infant associated with B19 infection. This is the first report of such infection in an infant in English literature. Beom Joon Kim, MD Kwang Ho Yoo, MD Kapsok Li, MD Myeung Nam Kim, MD Department of Dermatology College of Medicine Chung-Ang University Seoul, Korea
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Nov 24, 2009
Li Zhang + 7
Open Access
