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Acute Parvovirus B19 Infection in Adults: A Retrospective Study of 49 Cases
Estudio retrospectivo de 49 casos de infección aguda por parvovirus B19 en adultos
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Ruiz" "apellidos" => "Bravo-Burguilllos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "D. Montero" "apellidos" => "Vega" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 5 => array:3 [ "nombre" => "C. Vidaurrázaga" "apellidos" => "Díaz-Arcaya" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio Anatomía Patológica, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio Microbiología, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Estudio retrospectivo de 49 casos de infección aguda por parvovirus B19 en adultos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 732 "Ancho" => 976 "Tamanyo" => 154028 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Palpable purpura on the leg clinically consistent with vasculitis, which was confirmed histologically.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Parvovirus B19 infection is uncommon in adults, and few cases have been described in the literature. A greater understanding of the epidemiologic, clinical, and laboratory characteristics of this infection in adults is important, as early recognition of signs and symptoms can help to prevent the spread of infection among at-risk individuals.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Parvovirus B19 is a small, nonenveloped, single-stranded DNA virus discovered by chance by Yvonne Cossart and her team in 1975 during blood screening for hepatitis B.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It is the only member of the Parvoviridae family that can cause disease in humans. It is an airborne virus with an incubation period of 13 to 17 days.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It has a particular tropism for red blood cell progenitors and endothelial cells, as it binds to the P antigen in the cell membranes.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Parvovirus B19 generally infects children of school-going age at the end of the winter and is more common in regions with a temperate climate.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In a third of cases, the infection is asymptomatic. In the remaining cases, it causes erythema infectiosum or the fifth disease, which typically presents with a malar rash that spares the nose and eye regions, giving what is known as the <span class="elsevierStyleItalic">slapped cheek</span> appearance. This is followed by a lacy rash on the trunk and limbs.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,5</span></a> Not all patients develop systemic manifestations, such as fever and joint pain, and when they do, they are usually mild.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Between 60% and 80% of adults have parvovirus B19 immunoglobulin (Ig) G antibodies,<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> explaining why symptoms are much less common in adults than in children. However, in contrast to children, adults in the symptomatic stage can spread the infection,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> hence the importance of early diagnosis.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In otherwise healthy adults, acute parvovirus B19 infection is generally self-limiting. It primarily affects women in their fourth or fifth decades and manifests most frequently as fever, rash, and symmetric, peripheral polyarticular pain.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Skin lesions are typically purpuric and can be generalized (with a distal, symmetric distribution)<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> or localized (with an asymmetric distribution).<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In patients with risk factors, acute parvovirus B19 infection can lead to serious complications, such as aplastic crisis in patients with hemoglobinopathies,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> chronic anemia in immunodepressed individuals,<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,13</span></a> and hydrops fetalis in pregnant women.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The aim of this article is to describe the typical epidemiological, clinical, and laboratory features of acute parvovirus B19 infection in adults in our setting.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and Methods</span><p id="par0040" class="elsevierStylePara elsevierViewall">We performed a retrospective, descriptive study of adult patients diagnosed with acute parvovirus B19 infection at Hospital General Universitario La Paz, in Madrid, Spain in 2012.</p><p id="par0045" class="elsevierStylePara elsevierViewall">We included men and women aged over 18 years who tested positive for IgM antibodies to parvovirus B19 during the study period. The antibodies were measured by enzyme-linked immunosorbent assay (Biotrin).</p><p id="par0050" class="elsevierStylePara elsevierViewall">Two patients with positive parvovirus B19 IgM antibodies were classified as false positives and excluded from the study. They both had high levels of Epstein-Barr virus (EBV) IgM, negative EBV nuclear antigen IgG, and low parvovirus B19 IgM levels. The results were therefore interpreted as a cross-reaction in patients with infectious mononucleosis.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The following variables were recorded for all patients studied: date of diagnosis; department in which the diagnosis was made (dermatology, rheumatology, internal medicine, or other), patient age and sex, personal history of interest, cutaneous and noncutaneous manifestations, blood alterations, liver profile, kidney profile, C-reactive protein (CRP) levels, antinuclear antibodies (ANAs), histologic findings in skin biopsies, and clinical outcome. The concomitant detection of IgM antibodies specific to other viruses was also recorded to investigate the possibility of cross-reactions.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall">Forty-nine adults (40 women and 9 men) had a positive parvovirus B19 IgM result during the study period (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Their ages ranged from 20 to 82 years and 90% were aged between 20 and 46. The mean age was 37.5 years and the mean and mode were both 36. There was a peak in incidence in June (12 cases) and July (16 cases). Only 3 cases were diagnosed in autumn and winter.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0415" class="elsevierStylePara elsevierViewall">Three patients were receiving immunosuppressants to treat an underlying disease and classified as immunosuppressed. One was receiving azathioprine and hydroxychloroquine to treat systemic lupus erythematosus, while the other 2 were receiving periodic infusions of infliximab to treat rheumatoid arthritis in one case and hidradenitis suppurativa in the other. A fourth patient was considered to be immunocompromised due to advanced age and multiple comorbidities. Five patients were identified as at risk because of pregnancy.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Skin lesions, present in 27 patients (55.1%), were the most common clinical finding. Joint pain was the most common systemic manifestation of infection and was reported by 26 patients (53.1%). Most of these patients described symmetric, polyarticular pain in the phalanges, wrists, ankles, elbows, and knees. Several patients, however, had monoarthritis affecting the central axis of the body, and reported cervical pain, lower back pain, and hip pain. Twenty patients (40.8%) had fever, but their temperature generally remained under 38.5°C. Important diagnostic clues in our series included enlarged lymph nodes in the lateral cervical chains (3 cases), weakness or asthenia (3 cases), and swelling of the feet and hands (1 case).</p><p id="par0075" class="elsevierStylePara elsevierViewall">The most common skin lesion was purpuric exanthema, which was largely symmetric and present on the trunk and limbs (12 cases). Six patients had purpuric lesions consistent with the papular-purpuric gloves and socks syndrome (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), and 9 patients had palpable purpura clinically consistent with vasculitis on the anterior surface of the lower limbs (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 2</a>). One patient had intense swelling of the legs, feet, forearms, and hands, with epidermal detachment, erosions, and purpura.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Suspected cases of vasculitis were confirmed by histologic examination of skin biopsy samples. The examination revealed superficial perivascular inflammation that also affected the deep dermis in 1 case, dilated vessels with endothelial swelling, fibrinoid necrosis of vessels, and nuclear dust (leukocytoclasis) (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 3</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Serology tests were ordered by the following departments: dermatology (23 cases), internal medicine (9 cases), rheumatology (9 cases), hematology (3 cases), gynecology (3 cases), and microbiology (1 cases); 1 test was also ordered by a primary care center.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Blood tests revealed 6 cases of mild anemia (12.2%), 4 of which resolved spontaneously. Two immunocompromised patients—the elderly patient with multiple comorbidities and a 75-year-old patient with rheumatoid arthritis under treatment with infliximab—were referred to the hematology department with persistent anemia. White blood cell alterations—mainly lymphopenia, monocytosis, and neutrophilia—were detected in 15 patients (30.6%). Three patients (6.1%) had thrombocytosis. CRP levels were mildly to moderately elevated in 15 patients (30.6%). There were 5 cases (10.2%) of mild to moderate elevations of transaminase levels, which normalized spontaneously. One patient tested positive for ANAs, despite previous negative tests. It should be noted, however, that an ANA test was ordered only for 21 patients (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><p id="par0095" class="elsevierStylePara elsevierViewall">Parvovirus B19 infection was self-limiting in 75.5% of patients. In 20.4% of cases, systemic corticosteroids were used to provide symptomatic relief. This treatment was particularly effective in patients with clinical features of vasculitis and in the patient with intense swelling. Nine patients improved following the administration of 12<span class="elsevierStyleHsp" style=""></span>mg of intramuscular betamethasone. The patient with vasculitis of the superficial and deep vessels on histology required tapering doses of prednisone, starting at 0.5<span class="elsevierStyleHsp" style=""></span>mg/kg/d, with reductions of 10<span class="elsevierStyleHsp" style=""></span>mg every 10 days. The 2 older patients are still being monitored for chronic anemia. The 5 pregnant women underwent weekly ultrasound examinations, and no complications were observed.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Positive IgM antibodies against EBV were observed in 18.4% of cases; 6.1% of patients had a positive borderline IgM result, 8.1% had a negative borderline IgM result, and 6.1% had an equivocal IgM result. In all cases, however, IgM titers were much higher for parvovirus B19 and practically negligible for EBV, indicating that EBV IgM positivity was the result of a cross-reaction. None of the patients tested positive for cytomegalovirus IgM antibodies. Serology tests for measles and rubella were ordered in very few cases.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">We have described the epidemiologic, clinical, and laboratory characteristics of acute parvovirus B19 infection in 49 adults. Based on our review of the literature, this is the largest such series published to date. The high incidence of cases in such a short space of time lends weight to the theory that parvovirus B19 infection occurs in epidemic cycles.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15–17</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Coinciding with previous reports, we observed that acute parvovirus B19 infection is more common in young women<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and occurs more frequently in late spring and in summertime.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">The literature suggests that systemic manifestations such as joint pain and fever are more common than skin lesions in adults,<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19–21</span></a> but in our series, skin lesions were the most common clinical finding.</p><p id="par0120" class="elsevierStylePara elsevierViewall">The heterogeneous distribution of purpuric exanthemas observed in our patients is also consistent with previous reports of acute parvovirus B19 infection in adults.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,8</span></a> This infection is considered to be one of the main causes of papular-purpuric gloves and socks syndrome, first described in 1990,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> and is in fact believed to be responsible for 80% of all cases. Associations with other viruses, namely, EBV, cytomegalovirus, hepatitis virus B, varicella-zoster virus, human herpes viruses 6 and 7, measles virus, rubella virus, and coxsackievirus, have also been described.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Papular-purpuric gloves and socks syndrome consists of erythema and swelling of the feet and hands that can cause pruritus, pain, and a burning sensation. The erythema is sharply demarcated at the wrists and ankles, and progresses to purpuric lesions that spread centripetally and may be accompanied by mucosal lesions and systemic involvement.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23–25</span></a> The histologic features of papular-purpuric gloves and socks syndrome are nonspecific and include varying degrees of epidermal spongiosis, foci of parakeratosis, a mild perivascular infiltrate around the superficial dermal vascular plexus, and extravasated red blood cells around the superficial capillaries of the dermis.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Over 70 cases of papular-purpuric gloves and socks syndrome associated with parvovirus B19 have been reported to date,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and our series adds a further 6 cases.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Parvovirus B19 has been implicated in the etiology of vasculitis,<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> but few cases have been described. Clearly, the most remarkable finding in our series is the high frequency of skin lesions clinically consistent with vasculitis in patients with no other evident cause of this inflammation. Over 18% of patients had palpable purpura on the lower limbs, and one had necrotic lesions, indicating the severity of the condition.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Based on existing reports, joint pain and fever are the most common manifestations of acute parvovirus B19 infection in adults.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18–20</span></a> While these conditions were common in our series, they were outnumbered by skin lesions. Other signs and symptoms described in the literature, such as enlarged lymph nodes, weakness or asthenia, and swelling,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> should raise suspicion of acute parvovirus B19 infection in patients with a compatible clinical presentation.</p><p id="par0135" class="elsevierStylePara elsevierViewall">Anemia was detected in 12.2% of our patients; this rate is much lower the rate of over 80% reported elsewhere.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> The condition, however, was, as is commonly described, self-limiting in immunocompetent patients. The fact that anemia persisted in 2 immunocompromised patients in our series may be related to the chronification of infection (which has been previously described in immunodepressed patients), as the onset of anemia coincides with the detection of parvovirus IgM antibodies in blood samples. White blood cell alterations—particularly lymphopenia, monocytosis, and neutrophilia—were the most common blood alterations detected in our series, and contrasting with previous reports, we observed thrombocytosis (3 cases) rather than thrombocytopenia.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Also, although transient elevation of transaminases is very common, affecting almost 90% of patients in other series,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> only 10.2% of the patients in our series had raised transaminase levels.</p><p id="par0140" class="elsevierStylePara elsevierViewall">None of the patients in our series developed serious disease, although the literature contains isolated reports of acute parvovirus B19 infection associated with acute fulminant hepatitis,<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">27</span></a> acute glomerulonephritis,<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">28</span></a> acute encephalitis and peripheral neuropathy,<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">29</span></a> myocarditis, and aplastic anemia in both immunocompetent and immunocompromised patients.</p><p id="par0430" class="elsevierStylePara elsevierViewall">Parvovirus B19 infection has been reported in association with a wide variety of autoimmune disorders, including juvenile rheumatoid arthritis, reactive arthritis, systemic lupus erythematosus, dermatomyositis, polymyositis, systemic sclerosis, primary biliary cirrhosis, and autoimmune cytopenia.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">30–32</span></a> According to Lunardi et al., <a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">30</span></a> parvovirus B19 might not only have a lytic effect on endothelial cells and a cytotoxic effect on platelet progenitors, but also lead to the production of antibodies that, through cross-reactivity, could attack autoantigens and possibly induce autoimmune disease. This theory would explain the high frequency of vasculitis in our series. A systematic study of autoantibodies involving more patients followed for a longer time is needed to demonstrate that parvovirus B19 infection is capable of inducing not only an autoimmune response but also an autoimmune disorder.</p><p id="par0150" class="elsevierStylePara elsevierViewall">Disease outcome was, as expected,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> favorable in our series, with clinical manifestations resolving spontaneously in under 2 weeks in most cases. Possible signs of persistent infection were present in immunodepressed patients, coinciding with observations in the majority of reports published.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Little has been published on the treatment of acute parvovirus B19 infection, probably because when the infection does cause symptoms, these tend to be self-limiting. A number of articles have described the successful use of immunoglobulin infusion therapy in the treatment of persistent infection.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,31</span></a> Long-term administration of systemic corticosteroids has been associated with an increased risk of infections.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> However, in a systematic review of parvovirus B19 infection associated with neurological manifestations, Barah et al.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> reported that a combined regimen of systemic corticosteroids and immunoglobulin infusion therapy was effective.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> In our series, clinical improvement occurred rapidly in patients treated with systemic corticosteroids.</p><p id="par0160" class="elsevierStylePara elsevierViewall">Pregnant women with acute parvovirus B19 infection must undergo regular examinations to monitor for fetal distress. The examinations should be weekly up to the end of pregnancy, as the risk of fetal involvement can persist for months after the resolution of symptoms.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">We detected a high rate of cross-reactivity with EBV, with slightly positive, borderline, and equivocal IgM found in 38.7% of patients. Cross-reactions between parvovirus B19 and EBV, cytomegalovirus, rubella, and measles have been previously reported.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35,36</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Early detection of acute parvovirus B19 infection in adults can result in important epidemiological benefits. The infection should be suspected in any patient with a purpuric rash, regardless of its distribution, and particularly if the patient is a young woman, seen in the spring or summer months, with fever and joint pain. The presence of skin lesions, presenting as either nonpalpable purpura (papular-purpuric gloves and socks syndrome) or palpable purpura (probably vasculitis), is particularly suggestive. The differential diagnosis should include other viral infections and conditions involving purpuric lesions, such as capillaritis, which manifests as purpuric lesions on the legs and also occurs in young women in the spring and summer. Capillaritis, however, does not tend to affect the dorsal or plantar surfaces of the feet and is not accompanied by fever, joint pain, or general malaise.</p><p id="par0175" class="elsevierStylePara elsevierViewall">Our findings are likely to be affected by some bias due to the descriptive and retrospective nature of the study. Although to our knowledge our series is the largest yet published on adult parvovirus B19 infection, even larger studies are required to be able to draw conclusions that can be more accurately extrapolated to our setting. Also needed are prospective studies that apply standardized protocols for ordering serology tests and that span several years to cover the epidemic nature of parvovirus B19 infection.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Ethical Disclosures</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Protection of humans and animals</span><p id="par0435" class="elsevierStylePara elsevierViewall">The authors declare that no tests were carried out in humans or animals for the purpose of this study.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Confidentiality of data</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors declare that they have followed their hospital's protocol on the publication of data concerning patients and that all patients included in the study have received sufficient information and have given their written informed consent to participate in the study.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Right to privacy and informed consent</span><p id="par0400" class="elsevierStylePara elsevierViewall">The authors declare that no private patient data appear in this article.</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicts of Interest</span><p id="par0195" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres418515" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec401971" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres418514" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec401972" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:3 [ "identificador" => "sec0035" "titulo" => "Ethical Disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Protection of humans and animals" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of Interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-01-07" "fechaAceptado" => "2014-06-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec401971" "palabras" => array:5 [ 0 => "Parvovirus B19" 1 => "Adults" 2 => "Exanthema" 3 => "Vasculitis" 4 => "Anemia" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec401972" "palabras" => array:5 [ 0 => "Parvovirus B19" 1 => "Adultos" 2 => "Exantema" 3 => "Vasculitis" 4 => "Anemia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Our aim was to describe the epidemiologic, clinical, and laboratory characteristics of acute parvovirus B19 infection in adults.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">This study describes all cases of acute parvovirus B19 infection in patients older than 18 years of age who were treated at Hospital Universitario La Paz in Madrid, Spain, in 2012.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Forty-nine adults were treated for acute parvovirus B19 infection. Most were young women who were infected in the spring or early summer. In over half the cases skin lesions were key diagnostic signs. We saw the full range of types of rash of purplish exanthems that were fairly generalized; vasculitis was relatively common (in ><span class="elsevierStyleHsp" style=""></span>18%). Mild or moderate abnormalities in blood counts and indicators of liver dysfunction resolved spontaneously in all but 2 immunocompromised patients, who developed chronic anemia.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">This is the largest case series of acute parvovirus B19 infection published to date. This infection should be suspected on observing signs of purplish skin rashes, no matter the location or pattern of distribution, or vasculitis, especially if accompanied by fever and joint pain in young women in the spring. Measures to avoid infection should be recommended to individuals at risk.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">El objeto de nuestro trabajo es describir las características epidemiológicas, clínicas y analíticas de la infección aguda por parvovirus B19 en adultos.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Presentamos un estudio descriptivo retrospectivo de todos los casos de infección aguda por parvovirus B19, en mayores de 18 años, durante el año 2012, en el Hospital Universitario La Paz, Madrid.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Cuarenta y nueve pacientes adultos con infección aguda por parvovirus B19. La mayoría ocurrieron en mujeres jóvenes en primavera y principios de verano. La lesión cutánea fue el signo fundamental para el diagnóstico en más del 50% de los casos. Se encontraron todo tipo de exantemas purpúricos más o menos generalizados, siendo relativamente frecuente la forma de vasculitis (><span class="elsevierStyleHsp" style=""></span>18%). Las alteraciones en el hemograma y perfil hepático, leves o moderadas, se resolvieron espontáneamente, salvo en 2 pacientes inmunodeprimidos en quienes persistió una anemia crónica.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Es la serie más amplia de infección aguda por parvovirus B19 descrita, hasta la fecha, en la literatura. Ante exantemas purpúricos de cualquier distribución o lesiones de vasculitis, sobre todo si se acompañan de fiebre y artralgias y se presentan en mujeres jóvenes en primavera, debemos sospechar una infección aguda por parvovirus B19 y recomendar medidas para evitar el contagio a personas de riesgo.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Rodríguez Bandera AI, Arenal MM, Vorlicka K, Bravo-Burguilllos ER, Vega DM, Díaz-Arcaya CV. Estudio retrospectivo de 49 casos de infección aguda por parvovirus B19 en adultos. Actas Dermosifiliogr. 2015;106:44–50.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 732 "Ancho" => 976 "Tamanyo" => 152858 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Purpuric exanthema with a sock-like appearance.</p>" ] ] 1 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 732 "Ancho" => 976 "Tamanyo" => 154028 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Palpable purpura on the leg clinically consistent with vasculitis, which was confirmed histologically.</p>" ] ] 2 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 527 "Ancho" => 1400 "Tamanyo" => 261279 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">A, Mixed superficial and deep perivascular inflammation (panoramic view, hematoxylin-eosin, original magnification ×2). B, Higher magnification view of fibrinoid necrosis of vessel, perivascular inflammatory infiltrate, and nuclear dust or leukocytoclastia (hematoxylin-eosin, original magnification ×10).</p>" ] ] 3 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No. of Patients \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">% of Patients \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleBold">Epidemiology</span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Sex</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Women \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">82 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Men \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Age, y</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>18-30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">27 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>31-40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">45 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>41-50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Time of diagnosis</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Winter (January-March) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Spring (April-June) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Summer (July-September) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">51 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Autumn (October-December) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Diagnosing department</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Dermatology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">47 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Rheumatology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Internal medicine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Gynecology/obstetrics \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Hematology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Others (microbiology, primary care center) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleBold">Clinical manifestations</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Skin lesions</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">55 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Exanthema \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Gloves and socks syndrome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Vasculitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Edema \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Joint pain</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">53 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Fever</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">41 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Enlarged lymph nodes</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Asthenia</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleBold">Laboratory findings</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Blood alterations</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">49 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Anemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Thrombocytosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>White blood cell alterations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">31 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Hypertransaminasemia</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Elevated C-reactive protein</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Positive antinuclear antibodies</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab655953.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Characteristics of Acute Parvovirus B19 Infection in Adults.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:36 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dermatology" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.L. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 20 | 13 | 33 |
| 2024 Octubre | 165 | 69 | 234 |
| 2024 Septiembre | 262 | 74 | 336 |
| 2024 Agosto | 269 | 123 | 392 |
| 2024 Julio | 231 | 98 | 329 |
| 2024 Junio | 273 | 125 | 398 |
| 2024 Mayo | 236 | 115 | 351 |
| 2024 Abril | 146 | 89 | 235 |
| 2024 Marzo | 205 | 63 | 268 |
| 2024 Febrero | 205 | 66 | 271 |
| 2024 Enero | 163 | 60 | 223 |
| 2023 Diciembre | 211 | 37 | 248 |
| 2023 Noviembre | 167 | 35 | 202 |
| 2023 Octubre | 128 | 57 | 185 |
| 2023 Septiembre | 135 | 67 | 202 |
| 2023 Agosto | 134 | 34 | 168 |
| 2023 Julio | 161 | 78 | 239 |
| 2023 Junio | 142 | 54 | 196 |
| 2023 Mayo | 145 | 66 | 211 |
| 2023 Abril | 77 | 64 | 141 |
| 2023 Marzo | 75 | 65 | 140 |
| 2023 Febrero | 99 | 43 | 142 |
| 2023 Enero | 78 | 45 | 123 |
| 2022 Diciembre | 63 | 52 | 115 |
| 2022 Noviembre | 33 | 38 | 71 |
| 2022 Octubre | 36 | 31 | 67 |
| 2022 Septiembre | 28 | 33 | 61 |
| 2022 Agosto | 36 | 56 | 92 |
| 2022 Julio | 33 | 57 | 90 |
| 2022 Junio | 25 | 53 | 78 |
| 2022 Mayo | 61 | 46 | 107 |
| 2022 Abril | 78 | 49 | 127 |
| 2022 Marzo | 72 | 62 | 134 |
| 2022 Febrero | 54 | 27 | 81 |
| 2022 Enero | 41 | 70 | 111 |
| 2021 Diciembre | 35 | 52 | 87 |
| 2021 Noviembre | 49 | 52 | 101 |
| 2021 Octubre | 57 | 49 | 106 |
| 2021 Septiembre | 46 | 43 | 89 |
| 2021 Agosto | 47 | 41 | 88 |
| 2021 Julio | 36 | 32 | 68 |
| 2021 Junio | 70 | 49 | 119 |
| 2021 Mayo | 36 | 28 | 64 |
| 2021 Abril | 67 | 67 | 134 |
| 2021 Marzo | 67 | 34 | 101 |
| 2021 Febrero | 86 | 33 | 119 |
| 2021 Enero | 45 | 26 | 71 |
| 2020 Diciembre | 40 | 29 | 69 |
| 2020 Noviembre | 30 | 29 | 59 |
| 2020 Octubre | 24 | 21 | 45 |
| 2020 Septiembre | 35 | 18 | 53 |
| 2020 Agosto | 35 | 41 | 76 |
| 2020 Julio | 37 | 21 | 58 |
| 2020 Junio | 55 | 36 | 91 |
| 2020 Mayo | 49 | 37 | 86 |
| 2020 Abril | 37 | 34 | 71 |
| 2020 Marzo | 36 | 35 | 71 |
| 2020 Febrero | 8 | 20 | 28 |
| 2020 Enero | 3 | 14 | 17 |
| 2019 Diciembre | 6 | 28 | 34 |
| 2019 Noviembre | 2 | 10 | 12 |
| 2019 Octubre | 0 | 16 | 16 |
| 2019 Septiembre | 10 | 23 | 33 |
| 2019 Agosto | 4 | 28 | 32 |
| 2019 Julio | 4 | 25 | 29 |
| 2019 Junio | 4 | 42 | 46 |
| 2019 Mayo | 6 | 116 | 122 |
| 2019 Abril | 2 | 77 | 79 |
| 2019 Marzo | 10 | 27 | 37 |
| 2019 Febrero | 3 | 27 | 30 |
| 2019 Enero | 1 | 12 | 13 |
| 2018 Diciembre | 11 | 9 | 20 |
| 2018 Noviembre | 1 | 8 | 9 |
| 2018 Septiembre | 8 | 22 | 30 |
| 2018 Agosto | 0 | 49 | 49 |
| 2018 Julio | 0 | 31 | 31 |
| 2018 Junio | 0 | 45 | 45 |
| 2018 Mayo | 0 | 43 | 43 |
| 2018 Abril | 0 | 13 | 13 |
| 2018 Marzo | 12 | 12 | 24 |
| 2018 Febrero | 108 | 17 | 125 |
| 2018 Enero | 97 | 81 | 178 |
| 2017 Diciembre | 76 | 34 | 110 |
| 2017 Noviembre | 83 | 44 | 127 |
| 2017 Octubre | 70 | 35 | 105 |
| 2017 Septiembre | 64 | 40 | 104 |
| 2017 Agosto | 70 | 47 | 117 |
| 2017 Julio | 70 | 49 | 119 |
| 2017 Junio | 82 | 89 | 171 |
| 2017 Mayo | 72 | 43 | 115 |
| 2017 Abril | 58 | 29 | 87 |
| 2017 Marzo | 63 | 58 | 121 |
| 2017 Febrero | 55 | 32 | 87 |
| 2017 Enero | 27 | 35 | 62 |
| 2016 Diciembre | 48 | 23 | 71 |
| 2016 Noviembre | 64 | 28 | 92 |
| 2016 Octubre | 24 | 40 | 64 |
| 2016 Septiembre | 0 | 23 | 23 |
| 2016 Agosto | 0 | 25 | 25 |
| 2016 Julio | 8 | 11 | 19 |
| 2016 Junio | 22 | 7 | 29 |
| 2016 Mayo | 21 | 5 | 26 |
| 2016 Abril | 26 | 2 | 28 |
| 2016 Marzo | 20 | 2 | 22 |
| 2016 Febrero | 11 | 2 | 13 |
| 2016 Enero | 15 | 2 | 17 |
| 2015 Diciembre | 5 | 3 | 8 |
| 2015 Noviembre | 7 | 4 | 11 |
| 2015 Octubre | 15 | 2 | 17 |
| 2015 Septiembre | 10 | 3 | 13 |
| 2015 Agosto | 8 | 4 | 12 |
| 2015 Julio | 120 | 14 | 134 |
| 2015 Junio | 33 | 7 | 40 |
| 2015 Mayo | 36 | 11 | 47 |
| 2015 Abril | 24 | 12 | 36 |
| 2015 Marzo | 25 | 11 | 36 |
| 2015 Febrero | 8 | 3 | 11 |
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