Clinical Quiz: The Rosy Cheeked Child

A quick spot-diagnosis quiz for this common childhood presentation.

The case:

A 4 year old child is sent home from daycare with a bright red facial rash on the cheeks. He has been otherwise well, although his mother reports that several other family members had cold symptoms a couple of weeks ago. On examination he is active and alert, well hydrated, afebrile, with an unremarkable ENT and cardiorespiratory examination. Apart from the facial erythema, he has no other rashes. Here’s a picture:

Picture published with consent.

Picture published with consent.

Questions:

1. What is the diagnosis?

2. When can he return to daycare?

3. His mother is also your patient. What would you tell her if she was 15 weeks pregnant? What about 25 weeks pregnant?

4. What is your subsequent management of her pregnancy?

Answers and discussion invited below. Stay tuned for my response next week.

 

***UPDATE***

Thanks to all who commented on the case in the comments below or via direct message. Answers and discussion:

1. Yes I agree! It’s almost certainly parvovirus B19 / slapped cheek syndrome / erythema infectiosum / fifth disease. The clue here is the  otherwise well child with an absence of other signs and symptoms. Also – the recent viral symptoms in family members may be a clue.

Keep in mind the differentials for facial erythema including different forms of dermatitis, rosacea, psoriasis, sunburn (!), lupus, erysipelas, keratosis pilaris rubra, etc.

2. Parvovirus viraemia begins about 6 days after infection and lasts for a week or so. The appearance of the rash correlates with formation of IgM antibodies and probably represents an immune mediated response, so by this time the infectious period has generally passed and kids don’t need to be isolated.

3. Up to 60% of pregnant women are immune to the virus, and the risk of infection in non-immune women is around 50% for household contact, 20-30% for women exposed in a school or childcare setting and <20% for other community contacts. If the mother is infected, the risk of transmission to the fetus is around 50%.

Parvovirus infection is usually very benign in immuno-competent people, but can result in fetal loss in the unborn child and this risk is significantly higher if transmission occurs before 20 weeks gestation (14.8% vs 2.3% in a pooled analysis of published data, see here, although note that the risk of fetal loss from other causes is also much higher in the first trimester so the loss attributable to parvovirus is more like 5-10%). Fetal hydrops can also occur although the risk is lower at 1%. There doesn’t seem to be an increased risk of congenital malformations.

4. Management of the pregnant woman with exposure to parvovirus involves:

  • Checking for immunity with parvovirus serology. IgG positive and IgM negative indicates immunity and suggests no need for further testing. IgG negative and IgM positive indicates recent infection. IgG and IgM negative indicates a patient susceptible to infection and serology can be repeated in 2-4 weeks to look for rising IgG titres.
  • Patients who are confirmed as acute infection during the pregnancy are usually screened with 1-2 weekly ultrasound scan for 6-12 weeks after maternal infection. If there are signs of fetal anaemia such as an increased MCA peak systolic velocity, or fetal hydrops such as ascites, pleural or pericardial effusion, then a referral to a tertiary centre for management is warranted.
  • Check local protocols or speak to your friendly maternal fetal medicine specialist for further advice!

Handy referernces:

Australasian Society of Infectious Diseases, “Management of Perinatal Infections”, 2002. 

South Australian Paediatric Clinical Guidelines

Society of Obstetricians and Gynaecologists of Canada Clinical Practice Guidelines

UK NICE guidelines

Dermnetnz information sheet

 

 

 

Advertisements

8 thoughts on “Clinical Quiz: The Rosy Cheeked Child

  1. 1. Slapped cheek syndrome or Fifth’s disease or Parvo B19 infection
    2. Now. Once the rash appears it is no longer infectious.
    3. That about 50% of women are immune to this condition and that it usually only causes a mild illness. Most babies are unaffected by the virus even when mother has no immunity. Occasionally there is severe foetal anaemia.
    4. There is no consensus opinion. Some recommend more frequent bloods and monitoring by ultrasound.

  2. Intrauterine parvo infection causes fetal anaemia and myositis and manifests as hydrops. It can be fatal. If Mum gets parvo then 50% of fetus are at risk. The outcome is generally worse prior to 20 weeks. Most infection is asymptomatic and runs a benign course from my reading.

    Mum is also at risk from red cell aplasia so a full blood count would be helpful especially if she complained of rash or arthralgia.

    I would also do maternal Parvo IgG and if positive provide reassurance that the pregnancy is not at risk. I often do this at booking for school teachers and other who may come into contact with someone with parvo.

    If Parvo IgG is negative, then Parvo IgM can be helpful deciding possible infection.

    If positive IgM, then check IgG in 2 weeks for a rising titre.as it may be a false positive IgM. I have been caught out when diagnosing a rash and arthralgia as Barmah Forest on the basis of a positive IgM without an IgG ever eventuating.

    I would organise ultrasound looking for hydrops every two weeks for the next 2 to 3 months. If there is evidence of hydrops I would phone a friendly tertiary centre obstetrician (ie WCH) and let them manage the hydrops. The fetus may require blood transfusion or delivery depending on gestation.

    Having said all that I have yet had to manage a case of maternal parvo.

    I have found that the SA Perinatal Guidelines offer a nice knowledge base for managing complications in pregnancy.

    http://www.sahealth.sa.gov.au/wps/wcm/connect/04ab65004ee541dda794afd150ce4f37/Parvovirus-slapped-cheek-synd-pregnancy-WCHN-PPG-08012013.pdf?MOD=AJPERES&CACHEID=04ab65004ee541dda794afd150ce4f37

  3. If the child have rash on the face with perioral “pallor” and also a rash on the trunk with possibly a red throat and glands, one has to think about Scarlet fever as well as scarlet fever can give red cheeks as well however usually with high fever.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s