418
ERYTHEMA INFECTIOSLJM-THE
with an associated port-wine nevus. Microembolization of the lesions permitted complete surgical removal with minimal blood loss. This case supports the theory of arteriovenous anastomosis being associated with the pathogenesis of pyogenic granulomas .
3. 4. 5. 6.
References
7. 1. Moriconi SE, Popowich LD: Alveolar pyogenic granuloma: Review and report of a case. Laryngoscope 94:807, 1984 2. Bhaskar SM. Jacoway, JR: Pyogenic granuloma clinical fea-
J Oral Maxillofac 49:419-419.
FIFTH DISEASE
tures, incidence, histology and results of treatment: Report of 242 cases. J Oral Surg 24:391, 1966 Eversole LS, Rovin S: Reactive lesions of the gingiva. Oral Surg 1:30, 1972 Leyden JJ, Mater GH: Oral cavity pyogenic granuloma. Arch Dermato126: 131, 1932 Wood NK, Goaz PW: Differential Diagnosis of Oral Lesions (ed 2). St Louis, MO, Mosby, 1980, pp 129-30 Swerlick RA, Cooper DH: Pyogenic granuloma (lobular capillary hemangioma) within port-wine stains. J Am Acad Dermatol8:627, 1983 Mills SE, Cooper PH, Fechner RE: Lobular capillary hemangioma: The underlying lesion of pyogenic granuloma. A study of 73 cases from oral and nasal mucous membranes. Am J Surg Path01 4:471, 1980
Surg
1990
Erythema Infectiosum-The
Fifth Disease:
Case Report HARRY DYM, DDS
Erythema infectiosum, a moderately contagious exanthematous disease affecting mainly children, is frequently called The Fifth Disease because it was the fifth of five illnesses described exhibiting somewhat similar rashes. ’ The other four diseases were rubella, measles, scarlet fever, and Filatou-Dukes disease (the last is now thought to be a mild atypical form of scarlet fever). The first recognized outbreak of this disease occurred in Germany and was described in 1889 by Tschammer,* who considered it a form of rubella. In 1899, Stricker3 described another epidemic and gave the disease its present name erythema infectiosum. It has been reported since in many other parts of the world, including the United States. This disease should be of interest to the oral and maxillofacial surgeon because its first presenting sign is a malar rash with no other prodromal symptoms. This article presents a case report of erythema infectiosum and a discussion of its clinical findings. * Assistant Director, Department of Dentistry, Woodhull Medical and Mental Health Center; Associate Director of Oral and Maxillofacial Surgery, The Brooklyn-Caledonian Hospital, Brooklyn, NY. Address correspondence and reprint requests to Dr Dym: Department of Oral and Maxillofacial Surgery, The BrooklynCaledonian Hospital, 121 DeKalb Ave, Brooklyn, NY 11201. 0 1990 American geons
Association
0278-2391/90/4804-0017$3.0010
of Oral and Maxillofacial
Sur-
Report of a Case In May 1987, a 6-year-old white girl was brought to the clinic because of a rash that suddenly appeared on the child’s cheeks. The patient’s past medical history was noncontributory. She was afebrile and stated she felt well. Head and neck examination showed a very bright exanthematous rash confined to the cheeks that was warm to touch but not tender (Fig 1). No lymphadenopathy was present and no significant oral findings were noted. The patient’s mother was advised to return the child the next day for follow-up. Upon return it was noted that her upper and lower extremities were covered with a maculopapular lacy rash (Fig 2). The patient’s pediatrician was consulted and a diagnosis of erythema infectiosum was made.
Discussion The cause of erythema infectiosum has only recently been shown to be viral. Anderson et al4 in 1984 investigated an extensive outbreak of the disease in a London primary school and reported good evidence to implicate the human parvovirus. Virologic and serologic studies of 36 typical cases of the disease revealed the presence of parvovirusspecific IgM antibody. There is no sex predilection, and infants and adults are rarely affected. The peak incidence is at age 7 years5 and most outbreaks occur in late winter and spring. The mechanism of transmission is unclear. Histologic study of skin biopsy specimens reveals a perivascular lymphocytic infiltration with edema of the dermis.
419
HARRYDYM
FIGURE 1. View of patient showing marked redness of the cheeks.
CLINICAL MANIFESTATIONS The incubation period is thought to range between 6 and 14 days, with the first sign of illness being the sudden appearance of livid erythema of the cheeks, giving the child a “slapped-cheek” appearance. No prodromal symptoms appear, and fe-
ver is usually absent. This eruption fades in 1 to 4 days. Approximately 1 day after the facial eruption, the rash enters its second stage. An erythematous maculopapular eruption initially appears on the proximal extremities, which soon spreads to the distal part of the extremities, buttocks, and trunk. During the second stage the lesions persist for several days to a week before they subside. As the rash fades, with central clearing, it takes on a lacy or reticulated appearance, which is the most distinctive part of the disease.6 After the rash has subsided, the disease enters its third stage. During this period, which last several weeks, the eruptions wax and wane, with recurrences precipitated by a variety of causes such as sunlight, emotional upset, rubbing of the skin, exercise, or warm baths. Complications do occur. Hemolytic anemia’ and encephalitis’ are rare complications that have been reported. Arthralgias and arthritis are seen in up to 50% of infected adults, although they are much less common in children. The prognosis is excellent, and no treatment is indicated. Isolation of children with this disease is not required. The differential diagnosis of this exanthematous disease includes systemic lupus erythematous, rubella, drug rashes, erysipelas, and atypical measles. Summary A case of erythema infectiosum (fifth disease) is discussed. As it is a childhood illness that initially presents with a facial rash, the oral and maxillofacial surgeon will often be the first practitioner to diagnose this interesting, but benign, disease. Acknowledgment The author is grateful to Wendy Montgomery and Hindy Dym for their help in preparation of this manuscript.
References
FIGURE 2. Appearance of lacy maculopapular rash extending over lower extremities.
1. Behrman RE, Vaughn VC, Nelson WE: Nelson Textbook of Pediatrics (ed 13). Philadelphia, PA, Saunders, 1987, p 661 2. Tschammer A: Verber orthche Rogheln. Jahrb Kinderh 1889, pp 29, 372 3. Snicker G: Die Neve Kinderseuche in der Umgebung von Giessen, 2 Prat Aerztl. 1899, pp 40, 121 4. Anderson MJ, Higgins PG, Davis LR, et al: Experimental parvoviral infection in humans. J Infect Dis 152:257, 1985 5. Hidano A. Oaihara Y. Orvu F, et al: Euidemioloav of an outbreak oferythema infectiosum in Tokyo. Int fbermato1 22: 161, 1983 6. Krugman S, Katz SL, Gershon AA, et al: Infectious Diseases of Children (ed 8). St Louis, MO, Mosby. 1985, p 72 7. Wadlington WB, Riley HD Jr: Arthritis and hemolytic anemia following erythema infectiosum. JAMA 203:473, 1968 8. Balfour HH Jr, Schiff GM, Bloom JE: Encephalitis associated with erythema infectiosum. J Pediatr 77: 133, 1970
ERYTHEMA INFECTIOSLJM-THE
with an associated port-wine nevus. Microembolization of the lesions permitted complete surgical removal with minimal blood loss. This case supports the theory of arteriovenous anastomosis being associated with the pathogenesis of pyogenic granulomas .
3. 4. 5. 6.
References
7. 1. Moriconi SE, Popowich LD: Alveolar pyogenic granuloma: Review and report of a case. Laryngoscope 94:807, 1984 2. Bhaskar SM. Jacoway, JR: Pyogenic granuloma clinical fea-
J Oral Maxillofac 49:419-419.
FIFTH DISEASE
tures, incidence, histology and results of treatment: Report of 242 cases. J Oral Surg 24:391, 1966 Eversole LS, Rovin S: Reactive lesions of the gingiva. Oral Surg 1:30, 1972 Leyden JJ, Mater GH: Oral cavity pyogenic granuloma. Arch Dermato126: 131, 1932 Wood NK, Goaz PW: Differential Diagnosis of Oral Lesions (ed 2). St Louis, MO, Mosby, 1980, pp 129-30 Swerlick RA, Cooper DH: Pyogenic granuloma (lobular capillary hemangioma) within port-wine stains. J Am Acad Dermatol8:627, 1983 Mills SE, Cooper PH, Fechner RE: Lobular capillary hemangioma: The underlying lesion of pyogenic granuloma. A study of 73 cases from oral and nasal mucous membranes. Am J Surg Path01 4:471, 1980
Surg
1990
Erythema Infectiosum-The
Fifth Disease:
Case Report HARRY DYM, DDS
Erythema infectiosum, a moderately contagious exanthematous disease affecting mainly children, is frequently called The Fifth Disease because it was the fifth of five illnesses described exhibiting somewhat similar rashes. ’ The other four diseases were rubella, measles, scarlet fever, and Filatou-Dukes disease (the last is now thought to be a mild atypical form of scarlet fever). The first recognized outbreak of this disease occurred in Germany and was described in 1889 by Tschammer,* who considered it a form of rubella. In 1899, Stricker3 described another epidemic and gave the disease its present name erythema infectiosum. It has been reported since in many other parts of the world, including the United States. This disease should be of interest to the oral and maxillofacial surgeon because its first presenting sign is a malar rash with no other prodromal symptoms. This article presents a case report of erythema infectiosum and a discussion of its clinical findings. * Assistant Director, Department of Dentistry, Woodhull Medical and Mental Health Center; Associate Director of Oral and Maxillofacial Surgery, The Brooklyn-Caledonian Hospital, Brooklyn, NY. Address correspondence and reprint requests to Dr Dym: Department of Oral and Maxillofacial Surgery, The BrooklynCaledonian Hospital, 121 DeKalb Ave, Brooklyn, NY 11201. 0 1990 American geons
Association
0278-2391/90/4804-0017$3.0010
of Oral and Maxillofacial
Sur-
Report of a Case In May 1987, a 6-year-old white girl was brought to the clinic because of a rash that suddenly appeared on the child’s cheeks. The patient’s past medical history was noncontributory. She was afebrile and stated she felt well. Head and neck examination showed a very bright exanthematous rash confined to the cheeks that was warm to touch but not tender (Fig 1). No lymphadenopathy was present and no significant oral findings were noted. The patient’s mother was advised to return the child the next day for follow-up. Upon return it was noted that her upper and lower extremities were covered with a maculopapular lacy rash (Fig 2). The patient’s pediatrician was consulted and a diagnosis of erythema infectiosum was made.
Discussion The cause of erythema infectiosum has only recently been shown to be viral. Anderson et al4 in 1984 investigated an extensive outbreak of the disease in a London primary school and reported good evidence to implicate the human parvovirus. Virologic and serologic studies of 36 typical cases of the disease revealed the presence of parvovirusspecific IgM antibody. There is no sex predilection, and infants and adults are rarely affected. The peak incidence is at age 7 years5 and most outbreaks occur in late winter and spring. The mechanism of transmission is unclear. Histologic study of skin biopsy specimens reveals a perivascular lymphocytic infiltration with edema of the dermis.
419
HARRYDYM
FIGURE 1. View of patient showing marked redness of the cheeks.
CLINICAL MANIFESTATIONS The incubation period is thought to range between 6 and 14 days, with the first sign of illness being the sudden appearance of livid erythema of the cheeks, giving the child a “slapped-cheek” appearance. No prodromal symptoms appear, and fe-
ver is usually absent. This eruption fades in 1 to 4 days. Approximately 1 day after the facial eruption, the rash enters its second stage. An erythematous maculopapular eruption initially appears on the proximal extremities, which soon spreads to the distal part of the extremities, buttocks, and trunk. During the second stage the lesions persist for several days to a week before they subside. As the rash fades, with central clearing, it takes on a lacy or reticulated appearance, which is the most distinctive part of the disease.6 After the rash has subsided, the disease enters its third stage. During this period, which last several weeks, the eruptions wax and wane, with recurrences precipitated by a variety of causes such as sunlight, emotional upset, rubbing of the skin, exercise, or warm baths. Complications do occur. Hemolytic anemia’ and encephalitis’ are rare complications that have been reported. Arthralgias and arthritis are seen in up to 50% of infected adults, although they are much less common in children. The prognosis is excellent, and no treatment is indicated. Isolation of children with this disease is not required. The differential diagnosis of this exanthematous disease includes systemic lupus erythematous, rubella, drug rashes, erysipelas, and atypical measles. Summary A case of erythema infectiosum (fifth disease) is discussed. As it is a childhood illness that initially presents with a facial rash, the oral and maxillofacial surgeon will often be the first practitioner to diagnose this interesting, but benign, disease. Acknowledgment The author is grateful to Wendy Montgomery and Hindy Dym for their help in preparation of this manuscript.
References
FIGURE 2. Appearance of lacy maculopapular rash extending over lower extremities.
1. Behrman RE, Vaughn VC, Nelson WE: Nelson Textbook of Pediatrics (ed 13). Philadelphia, PA, Saunders, 1987, p 661 2. Tschammer A: Verber orthche Rogheln. Jahrb Kinderh 1889, pp 29, 372 3. Snicker G: Die Neve Kinderseuche in der Umgebung von Giessen, 2 Prat Aerztl. 1899, pp 40, 121 4. Anderson MJ, Higgins PG, Davis LR, et al: Experimental parvoviral infection in humans. J Infect Dis 152:257, 1985 5. Hidano A. Oaihara Y. Orvu F, et al: Euidemioloav of an outbreak oferythema infectiosum in Tokyo. Int fbermato1 22: 161, 1983 6. Krugman S, Katz SL, Gershon AA, et al: Infectious Diseases of Children (ed 8). St Louis, MO, Mosby. 1985, p 72 7. Wadlington WB, Riley HD Jr: Arthritis and hemolytic anemia following erythema infectiosum. JAMA 203:473, 1968 8. Balfour HH Jr, Schiff GM, Bloom JE: Encephalitis associated with erythema infectiosum. J Pediatr 77: 133, 1970
