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Questions from practice - slapped cheek syndrome

My six-year-old daughter’s cheeks have gone really red. It’s not slapped cheek syndrome is it?

by Sarah Marshall

Slapped cheek syndrome

Copyright 2009 Galderma

Slapped cheek syndrome


My six-year-old daughter’s cheeks have gone really red. It’s not slapped cheek syndrome is it?


Slapped cheek syndrome (also known as Fifth disease or erythema infectiosum) is caused by infection with parvovirus B19. Initial symptoms may be non-specific and influenza-like (eg, headache, mild fever, rhinitis, sore throat and tiredness).

A week or so after these symptoms have passed some patients go on to develop a rash on the face (giving a “slapped” appearance —  see picture) with a pale area around the mouth. The rash is usually painless (although it can be itchy) and can spread to the limbs and trunk.

It might fade and reappear for several weeks and can re-emerge if the patient is exposed to heat or sun. However 20 to 30 per cent of patients are asymptomatic.

The virus is highly infectious, being transmitted by respiratory droplets. It is most common in children aged six to 10 years, and it is estimated that at least 60 per cent of the population will have contracted it by the age of 20 years. Most cases occur in winter and spring and there are epidemics every few years.

By the time a rash presents the child is no longer contagious so does not have to be kept out of school or nursery.

Pharmacists should ask about accompanying symptoms and drug and immunisation history because slapped cheek syndrome can appear similar to rubella, measles (look for Koplik’s spots on buccal mucosa), scarlet fever (look for exudate on tonsils and strawberry tongue) or an allergic reaction (eg, to a drug or to suncream).

Occasionally, parvovirus can present with a purpuric rash similar to septicaemia or meningitis and, to be safe, pharmacists should look out for fever, cold hands and feet, leg pain, vomiting, headache, stiff neck, drowsiness, confusion or dislike of bright lights.

In children, infection with parvovirus B19 is usually mild and self-limiting, resulting in lifelong immunity. However, adults who contract the virus can suffer acute arthropathy, characterised by painful swollen joints. Although this generally resolves within a month, in some patients symptoms may be prolonged.

Parvovirus B19 is of particular concern in pregnancy because, if contracted in the first 20 weeks, it can lead to miscarriage. If contracted between nine and 20 weeks there is also a risk of fetal hydrops (where the fetus develops severe anaemia and oedema).

Pregnant women who think they have been exposed to the virus should see their GP, who should test for antibodies to the virus (if results are positive, ultrasound scanning is performed regularly to monitor for the development of hydrops and treatment given where necessary).

Because parvovirus B19 reproduces in red blood cell precursors, it can temporarily interrupt erythrocyte production. Thus in susceptible patients (eg, those with haematological conditions such as sickle cell anaemia) infection can lead to profound anaemia. Immunocompromised patients may suffer persistent infection leading to chronic anaemia.

The infection is usually diagnosed clinically but tests for antibodies to the virus or viral DNA may be used to confirm diagnosis in vulnerable patients or to distinguish between parvovirus B19 and measles or rubella infections.

There is no specific treatment for slapped cheek syndrome. Paracetamol or ibuprofen may be used to relieve fever and pain. Non-steroidal anti-inflammatory drugs may be used to treat arthropathy.

Patients suffering anaemia or immunodeficiency may require blood transfusions or intravenous immunoglobulin therapy.

Sarah Marshall is a practising pharmacist, Aberdeenshire

Citation: The Pharmaceutical Journal URI: 10971806

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