Making the Rounds

April 1, 2006

The patient, a 13-year-old girl, was concerned about the development of a very itchy, painful, papular rash on her hands and feet. She had been previously well and had no history of illness other than a minor upper respiratory tract infection 2 weeks earlier. The distribution of lesions and the severe pruritus initially suggested scabies, which was treated with 5% permethrin cream. The rash did not improve with applications of this medication, however, and the patient returned the following day for care. She had no oral lesions but complained of mildly painful, nonswollen joints.

Parvovirus B19 Infection

The patient, a 13-year-old girl, was concerned about the development of a very itchy, painful, papular rash on her hands and feet. She had been previously well and had no history of illness other than a minor upper respiratory tract infection 2 weeks earlier. The distribution of lesions and the severe pruritus initially suggested scabies, which was treated with 5% permethrin cream. The rash did not improve with applications of this medication, however, and the patient returned the following day for care. She had no oral lesions but complained of mildly painful, nonswollen joints.

Close inspection of the rash revealed a "glove-and-sock" distribution, which suggested Parvovirus infection. Blood tests were ordered: the white blood cell count was low at 2.6 3 109/L (normal, 4.5 to 11.0 3 109/L). The platelet count was also low at 81 3 109/L (normal, 150 to 450 3 109/L). Because this type of rash can sometimes be seen in patients who are infected with Cytomegalovirus or Epstein-Barr virus or who have hepatitis, blood was also sent for determination of Parvovirus titers. Parvovirus IgM and IgG titers were subsequently found to be significantly elevated, which confirmed acute infection.

Parvovirus B19 is a small, non-enveloped single-stranded DNA virus that was discovered in 1975 during study of the hepatitis B virus. The name B19 came from the blood bank code in which the original positive serum sample was labeled. The positive serum was number 19 in row B of a panel of sera.

Parvovirus B19 infection commonly occurs in the late winter or early spring. It primarily affects children between the ages of 6 and 14 years. There is a wide spectrum of clinical manifestations--dermatologic, rheumatologic, and hematologic. The infection can be asymptomatic, but the most common clinical presentation is erythema infectiosum, or fifth disease, characterized by the "slapped-cheek" appearance and lacy erythema of the proximal extremities. Once the rash appears, the child can no longer transmit the disease. (Please let all school nurses know!)

This patient presented with the gloves-and-socks syndrome, a lesser known variant characterized by a distinctive papular, purpuric eruption that occurs mostly in young adults. The erythematous exanthem of the hands and feet is associated with pain and mild edema. Although other parts of the body can be affected, there is typically a distinct border at the wrists and ankles that describes the gloves-and-socks distribution. A subsequent petechial rash may also occur, as in this patient, with or without thrombocytopenia. The palate, lips, or buccal mucosa can be involved. Immunocompetent persons generally appear nontoxic and have a favorable prognosis; immunocompromised patients may have more serious complications. *

Spontaneous Pneumomediastinum

The patient, a 17-year-old boy, was brought to the emergency department (ED) with pleuritic chest pain of acute onset. He had been on the school bus when he suddenly felt a pressing chest pain and shortness of breath. In the ED, he was noted to have decreased breath sounds in the right lower lung and a soft murmur with a friction rub. Chest films showed a normal cardiac and mediastinal silhouette but a positive pneumomediastinum (arrows) with air tracking superiorly into the neck.

The patient had been seen 2 years earlier by a cardiologist for palpitations. His ECG and echocardiographic findings were normal at that time. Because of the chest films and past medical history, another ECG was obtained; the results were normal. The patient had no recent history of blunt or penetrating trauma. He could not recall any obvious Valsalva maneuvers, such as forceful vomiting, coughing, or sneezing.

The patient's 2-day hospital course was uneventful. He was sent home with instructions to take over-the-counter medications for pain. He was also advised to follow up with a pediatric pulmonologist in a week and to avoid contact sports, scuba diving, and airplane travel for 6 months.

Half the cases of spontaneous pneumomediastinum have no obvious cause. Spontaneous pneumomediastinum is more likely to be associated with asthma, smoking, or illicit drug use,1 but this patient denied any history of these risk factors. *

Contact Dermatitis With Photoactivation

This 12-year-old boy decided to try his father's aftershave skin lotion on the dry skin around his eyes and mouth. The lotion contained several ingredients--tea tree oil, lavender fragrance, and aloe--that may have caused this reaction. The patient was advised to avoid this skin product and to be cautious when using other products containing these ingredients.

The patient had used his father's aftershave without incident several weeks earlier. When he applied the aftershave at the time this rash developed, he had been on a skiing trip in Utah where there was lots of sunshine. The ingredients may have been photoactivated; this was discussed with the patient and his mother. *

References:

FOR MORE INFORMATION:

m Abuhammour W, Abdel-Haq N, Asmar B. Picture of the month. Petechial eruption with parvovirus B19 infection.

Arch Pediatr Adolesc Med.

1999;153: 87-88.m Vafaie J, Schwartz RA. Parvovirus B19 infections.

Int J Dermatol.

2004;43:747-749.

REFERENCE:

1.

Newcomb AE, Clarke CP. Spontaneous pneumomediastinum: a benign curiosity or a significant problem?

Chest.

2005;128:3298-3302.