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Special Feature
November 01, 2010

Picture of the Month—Diagnosis

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Copyright 2010 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2010

Arch Pediatr Adolesc Med. 2010;164(11):1066. doi:10.1001/archpediatrics.2010.194-b
Denouement and Discussion: Parvovirus-Associated Papular-Purpuric “Gloves and Socks” Eruption, With Atypical Unilateral Facial Involvement in Locus Minoris Resistentiae

The relative lack of toxicity, the chronic course of the condition, and acral concentration of papules and petechiae indicated a papular-purpuric “gloves and socks” (PPGS) eruption.

Diagnostic studies performed included a complete blood count and C-reactive protein (both with normal results) and rapid strep test, monospot, and blood culture (all with negative results). Additional specific viral studies included a serology for cytomegalovirus (with negative results) and an IgM for parvovirus B19 and a polymerase chain reaction for parvovirus B19 (both with positive results). Incidentally, the results of the polymerase chain reaction for an influenza A test were also positive, indicative of recent immunization with the nasal live-attenuated vaccine.

In 1990, PPGS was first described in Switzerland in a case series of 5 patients. In these patients, the cutaneous symptoms were preceded by a history of drug administration, and results of viral serologies were negative.1The association with parvovirus B19 was discovered in 1991 when antiparvovirus B19 IgM antibodies were found in a patient with the infection.2Almost two-thirds of those with PPGS have had their condition associated with parvovirus B19 infections.3The remaining cases have been linked to infection with other agents, including Epstein-Barr virus, cytomegalovirus, human herpesvirus-6, and arcanobacterium hemolyticum.4,5

Patients with PPGS classically present with painful, symmetric edema and erythema of the hands and feet associated with petechial purpura that is sharply demarcated on the wrists and ankles.6Associated findings of oral and perioral mucosal petechiae and erosions are common and may be seen with systemic symptoms of malaise, arthralgias, and low-grade fever. Papular-purpuric “gloves and socks” syndrome typically spares the face, except the perioral area. This case demonstrates a highly unusual unilateral facial presentation of PPGS, including petechiae and papules at this site. The underlying explanation for this unusual manifestation remains unclear. However, the patient's mother describes the eruption happening on the right side of the face in response to application of topical calamine lotion. We speculate that a localized irritant or allergic contact dermatitis may have triggered the appearance of the rash at this site as a result of local hyperemia and as part of the phenomenon of locus minoris resistentiae. The concept refers classically to a so-called path of least resistance—that is, a situation in which microorganisms have a tendency to settle at sites of weakened resistance—as might be seen with a damaged heart valve or a site of trauma.

In contrast to classic fifth disease, in which the condition is no longer communicable by the time the so-called slapped cheek rash appears, patients with PPGS have been documented to remain viremic even when the skin findings are evident.7Appropriate isolation of these patients is indicated because of the potential for communicability. Patients at special risk of red cell aplasia or aplastic crisis include those with hematological diseases (sickle cell disease, thalassemia, and spherocytosis). Patients who are pregnant and nonimmune to parvovirus B19 are at risk of hydrops fetalis. Papular-purpuric “gloves and socks” syndrome is usually a self-limited infection that resolves in 1 to 2 weeks.8

Patients with PPGS may be mistaken for having Rocky Mountain spotted fever (RMSF), which classically begins as petechiae on the wrists and ankles with subsequent spread to the palms and soles and then displays a more generalized distribution. Those with RMSF typically present with fever, toxic appearance, electrolyte abnormalities, and myositis.9The soreness and pain from the myositis can often be elicited in large muscles. By contrast, the pain in PPGS is characteristically localized to the hands and feet.

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Article Information

Correspondence:Albert C. Yan, MD, Section of Dermatology, Division of General Pediatrics, The Children's Hospital of Philadelphia—University of Pennsylvania School of Medicine, 3550 Market St, 2nd Fl, Philadelphia, PA 19104 (

Accepted for Publication:March 31, 2010.

Author Contributions:Study concept and design: Shah and Yan. Acquisition of data: Yan. Analysis and interpretation of data: Shah, Dawn, and Yan. Drafting of the manuscript: Shah and Yan. Critical revision of the manuscript for important intellectual content: Shah, Dawn, and Yan. Obtained funding: Yan. Administrative, technical, and material support: Shah and Yan. Study supervision: Yan.

Financial Disclosure:None reported.

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 Diagnosis and Management of Tickborne Rickettsial Diseases: Rocky Mountain Spotted Fever, Ehrlichioses, and Anaplasmosis. Centers for Disease Control and Prevention Web site. Accessed August 22, 2010