Papular-purpuric " gloves and socks " syndrome caused by parvovirus B 19

This pllper presents a 15-year-old boy with an aCWe febrile illness accompallied by p"rpuric and papular lesions located mostly 011 the dorsal areas of his hands and feet with the additional changes 011 his knees Gnd elbows. Serologic studies cOllfinned the aCllle infection by parvovirus 819. Apart from mild leukocytosis there were no other ab"onJUlIities i" hematologic and laboratory findings. TI,e diagnosis of papular-purpuric "gloves alld socks" syndrome (PPGSSj was lIlade. ClHalleOUS changes completely resolved fWO weeks later. Herein the patient's condition was described together with a brief overview ofthe PPGSS literature concerning this relatively rare viral examhema.


Introduction
A characteristic rash consisting of papular and purpuric lesions covering the acral porlions of extremities.descriptively named papular-purpuric "gloves and socks" syndrome (PPOSS), was first reported in 1990 by Harms, Feldmann and Saur:lI (l).A year laLcr, the exanthcma was found to be associated with the acute infection with parvo• virus B 19 (2).The unique syndrome is characterized by pruritic erythema and edema of Lhe hands and feel with petechiae, fever.and oral erosions (3).This rare exanthema seems LO preferentially affect teenagers and adults, and resolves spontaneously wilhin 2 weeks.Lymphadenopathy has been frequently described in these patients (3).Systemic symptoms included asthenia.anorexia, fever and arthralgias.The highest incidence was reported to occur in spring and summer.
This paper reports a case of a boy with PPOSS in whom serological analysis confirmed the associ::llion of the exanthema with the acute infeclion with parvovirus 819.

Case report
A 15-year-old boy come to our outpatient clinic for a purpuric maculopapular rash, mild fever and a headache.
Skin changes and symptoms had begun the day before.On the examination, multiple purpuric and erythematous macules and papules were seen over the dorsal aspects of his hands and fect, whereas his knees.elbows and volar aspects of his forearms were studded with numerous erythematous and livid papules, some coalescing into smaller plaques (Fig. 1).The lesions were slightly tender.The patient's body temperature was elevated 10 37.8°C.There was a pharyngeal erythema and his tongue was a bit swolen and deeply red.Organomegaly, peripheral lymphadenopathy or any other abnormality were not found during the physical examination.Epidemiologic history did not elicit any relevant data.
Results of rouline laboratory investigations.including liver and renal function tests and urinalysis.were normal.The only alteration found was leukocytosis (15.3/nL) with elevated absolute numbers of both granulocytes (9.2JnL) and lymphocytes (4.6/nL).Enzyme immunoassay showed significant titers of 19M and IgG antibodies against parvovirus 819.whereas antibody results for cytomegalovirus.measles virus.hepatitis A. 8 and C virus.rubella virus.herpes simplex virus (HSV).varicella zoster virus (VZV) and Epstein-Barr virus (EBV) were negative or not consistent with the acute infection.Serological tests repeated three weeks later showed a fourfold risc in anti-parvovirus IgG liters.
In less Lhan Iwo weeks the eruption cleared spontane- Recently, a number of hematologic.rheumatologic and neurologic complications have been recognized.the aplastic anemia being rhe most serious among rhem.Parvovirus B 19 is thought to be transmillcd primarily by the respiratory route via droplet aerosol during the viremic phase (4).Apan from the c1assicaf cutaneous eruption seen in children, two other rashes have been associated with parvovirus BI9 infectionpapular-purpuric "gloves and socks" syndrome.and asymme[ric periflexural exan,hem of childhood (1-5).
Papular-purpuric "gloves and socks" syndrome is a self-limiting cutaneous eruption which has been linked to the parvQvirus 819 infection in at least 15 cases, including the pa'ien' described herein (2, 6-10).However, there were a number of patients in whom other viruses were related to the examhema: cytomegalovirus.measles virus.coxsackievirus-B6.Epstein~Barr virus.human herpes~virus 6, hepatitis 8 virus and rubella virus (6. 11-13).Papularpurpuric "gloves and socks" syndrome was desribcd in 5poj 2 H1V-positive palienls coinfeclCd with parvovirus BI9 (10).Also, in some cases no viral cause was found or a drug (trimethoprim/sulfamcthoxazole) was shown to induce the nIsh (14).It is obvious [l1at papular-purpuric "gloves and socks" syndrome represents a reaction pUllern caused by various agents, mostly viruses.It is believed that many clinical manifestations.including skin eruptions. of parvovirus B19 infection are a consequence of immune complex formation (4).Several groups of authors detected parvovirus B19 DNA in cutaneous lesions.and intracytoplasmic staining of dermal endothelial cells, keratinocytes and sweat glands showed an amibody against the virus (8. 15).The direct infection of dermal endothelial cells might result in the purpuric nature of the exumhem.A lrue vascuJilic process has nOI been described in Ihe syndrome so far.and histopalhologic findings still seem nonspecific (8).There are scarce data about Hcnoch•Schonlein purpura that occur concomilantly with papular-purpuric "gloves and socks" syndrome (16).
Cutaneous changes in papular-purpuric "gloves and socks" syndrome are char3cterislic enough to permit a struightforward clinical diagnosis.Beside the typical location of lesions on hands and feet, less frequcnlly cheeks, elbows.knees, inner <.lspects of thighs, glans penis.inguinal creases, and buttocks might be involved (I).Rarely.superficial skin necrosis might evolve from the lypic.!1 lesions (9).Mucosal involvement encompasses petechiae on the hard palate, vesiculopustules on the h<.lrd and soft palates, pharyngeal erythema.small erosions on the oral mucosa.and swollen lips with painful erosions (8).The exanthema mainly affects young adults.although pediatric cases were also described in the lileralUre.lhe youngest being 4 years old (7).
The infection with pnrvovirus B19 might thus induce a variety of cUUmcous changes ranging from a nonspecific maculopapular rash to more characteristic exanthems.like the fifth disease and papular-purpuric "gloves and socks" syndrome.Other complications of the infection could be renected in the skin (thrombocytopenic purpura and vasculitis) (4).Mucosal changes are by no means rare.Papular-purpuric "gloves and socks" syndrome is a self• limiting disease which requires no extensive laboratory workup in the absence or significanl eXlracutaneous changes.Searching for a viral agent, mainly parvovirus B19. and complete blood cell COUIllS with the differential one are sufficiem laboratory investig:lIions, unless clinical SlalUS dicta~es a more ex.tensivecheck-L!p.Bed rcst, antipyretics and bland emollients are usually the only therapeutic measures required.
Fig. 1 -Erythematous and purpuric macules and papules over the volar aspects of forearms.