Case for diagnosis

Caso para diagnóstico

WHAT IS YOUR DIAGNOSIS?

Case for diagnosis

Caso para diagnóstico

Gláucia Thomas Heckler^I; Nadja Magdalena Köhler Dal Ri^II; Hiram Larangeira de Almeida Júnior^III

^IMedical Resident in Dermatology, Pontifical Catholic University of Rio Grande do Sul (PUC-RS), Porto Alegre, Rio Grande do Sul, Brazil

^IIUndergraduate Medical Student, Federal University of Santa Maria (UFSM), Santa Maria, Rio Grande do Sul, Brazil

^IIIAssociate Professor/Adjunct Professor of Dermatology, Federal University of Pelotas (UFPel) and the Catholic University of Pelotas (UCPel), Pelotas, Rio Grande do Sul, Brazil

^{Mailing address}

ABSTRACT

Papular-purpuric gloves and socks syndrome is a rare, highly contagious dermatosis caused by parvovirus B19, which may result in the abrupt cessation of red blood cell production in patients with preexisting hematological diseases. It affects predominantly children and young adults and has an unusual presentation.

Keywords: Diagnosis; Exanthem; Extremities; Human Parvovirus B19.

RESUMO

A síndrome "gloves and socks" pápulo-purpúrica é uma dermatose incomum, altamente contagiosa, causada pelo parvovírus B19, que pode provocar interrupção aguda da produção de glóbulos vermelhos em pacientes com doenças hematológicas preexistentes. Acomete, principalmente, crianças e jovens, e tem uma apresentaçao nao-usual.

Palavras-chave: Diagnóstico; Exantema; Extremidades; Parvovírus B19 humano

CASE REPORT

A 44-year old white female receptionist, born and living in Porto Alegre, Rio Grande do Sul, Brazil sought medical treatment at the dermatology outpatient clinic complaining of papular, purpuric, pruriginous lesions on her hands and feet that had developed four days earlier accompanied by diarrhea and a fever that had abated after 24 hours. She had been treated with systemic corticoids and dexamethasone cream during this period; however, there was no improvement in her clinical condition. She presented laboratory test results (full blood count, kidney and liver function tests) of samples collected at the onset of the condition. All were normal. She denied any pertinent medical history and reported no similar cases of the disease in the family. She had not used any medication prior to the onset of the condition and did not suspect pregnancy.

Examination revealed a papular-purpuric exanthem with well-defined borders, limited exclusively to the hands and feet, as well as the presence of mouth aphthae (Figures 1 and 2).

DISCUSSION

Parvovirus infection consists of a rare dermatosis described for the first time by Harms et al. in 1990.¹ Those authors referred to this condition as "gloves and socks" syndrome because of the typical pattern of the exanthem, limited to the hands and feet. In 1991, Bagot and Revuz reported an association between this syndrome and human parvovirus B19 infection, raising the hypothesis of a viral etiology. ²

This virus is highly contagious up to the time at which the eruption appears and it is spread principally by air-carriage of respiratory droplets. ³ Parvovirus B19 infection may trigger the abrupt cessation of red blood cell production, causing transient aplastic crisis, chronic red cell aplasia, hydrops fetalis or congenital anemia. This condition occurs mainly in patients with diseases that clinically reduce the half-life of erythrocytes (e.g. iron deficiency anemia, human immunodeficiency virus infection, sickle-cell anemia, spherocytosis, thalassemia). ⁴

According to the majority of reports, papularpurpuric gloves and socks syndrome mainly affects children and young adults. Although the majority of parvovirus B19-infected patients are asymptomatic, they may present with mild or non-specific symptoms of a viral infection such as in the case described here. Children may present with malar rash, resulting in an appearance that resembles a "slapped cheek" (such as in erythema infectiosum). ³ In adults, on the other hand, the condition is characterized clinically by the eruption of papular-purpuric, monomorphic macules, accompanied by a pruriginous and painful edema that involves the distal extremities in a gloves and socks pattern. ⁵ Some authors have also reported signs and symptoms that occur during the course of the disease such as fever, asthenia, anorexia, arthralgia, lymphadenopathy, mucosal erosions and perineuritis. ^6-8

Should laboratory confirmation be necessary, the detection of specific immunoglobulin M antibodies is recommended in the case of immunocompetent patients and viral DNA testing for those in an aplastic crisis and for immunocompromised patients.⁴ In the case described here, the lesions were extremely characteristic, and there were systemic symptoms of a viral condition in regression. In addition, there had been no prior exposure to drugs, thus eliminating the possibility of a cutaneous drug reaction.

The course of the disease is generally favorable, although some patients require transfusions or intravenous immunoglobulin. The majority of patients make a full recovery, since the exanthem is self-limiting and disappears within one or two weeks. ^4,9

Received on 03.03.2011.

Approved by the Advisory Board and accepted for publication on 11.10.2011.

Conflict of interest: None

Financial funding: None

References

• 1. Harms M, Feldmann R, Saurat JH . Papular-purpuric "gloves and socks" syndrome. J Am Acad Dermatol. 1990;23:850-4.
• 2. Bagot M, Revuz J. Papular-purpuric "gloves and socks" syndrome: primary infection with parvovirus B19? J Am Acad Dermatol. 1991;25:341-2.
• 3. Frühauf J, Massone C, Müllegger RR .Bullous papular-purpuric gloves and socks syndrome in a 42-year-old female: molecular detection of parvovirus B19 DNA in lesional skin. J Am Acad Dermatol. 2009;60:691-5.
• 4. Servey JT, Reamy BV, Hodge J.David Clinical presentations of parvovirus B19 infection. Am Fam Physician. 2007;75:373-6.
• 5. Carlesimo M, Palese E, Mari E, Panasiti V, Picarelli A, Rossi A, et al. Gloves and socks syndrome caused by parvovirus B19 infection. Dermatol Online J. 2006;12:19.
• 6. Borradori L, Cassinotti P, Perrenoud D, Frenk E. Papular-purpuric "gloves and socks" syndrome. Int J Dermatol. 1994;33:196-7.
• 7. Halasz CL, Cormier D, Den M. Petechial glove and sock syndrome caused by parvovirus B19. J Am Acad Dermatol. 1992;27:835-8.
• 8. Aguilar-Bernier M, Bassas-Vila J, Torné-Gutiérrez JI, Martínez-García G, Aragoneses-Fraile H, Miranda-Romero A. Presence of perineuritis in a case of papuar purpuric gloves and socks syndrome associated with mononeuritis multiplex attributable to B19 parvovirus. J Am Acad Dermatol. 2006;54:896-9.
• 9. Smith SB, Libow LF, Elston DM, Bernert RA, Warschaw KE Gloves and socks syndrome: early and late histopathologic features. J Am Acad Dermatol. 2002;47:749-54.

*

This study was conducted at the Pontifical Catholic University of Rio Grande do Sul (PUC-RS), Porto Alegre, Rio Grande do Sul, Brazil.

Publication Dates

• Publication in this collection
  01 Oct 2012
• Date of issue
  Oct 2012

History

• Received
  03 Mar 2011
• Accepted
  11 Oct 2011