[Human parvovirus B19 infection. Update]

[Parvovirus B19 infections in adults]

Acute Parvovirus B19 (PVB19) infection is responsible for erythema infectiosum in children and non-specific polyarthralgias in immunocompetent adults associated with skin lesions and rarer manifestations (hepatic, neurological, cardiac or nephrological). In immunocompromised patients, cytopenias are more frequent and in some cases, viremia persists and is responsible for PVB19 chronic infection. PVB19 is responsible for pure red cell aplasia during chronic hemolytic diseases. Acute PVB19 infection is a differential diagnosis of some autoimmune diseases and has been suspected to be a trigger for some autoimmune diseases because of its ability to promote the emergence of autoimmune markers. Mechanisms of molecular mimicry, induction of apoptosis and activation of enzymes have been demonstrated, explaining in part the production of autoantibodies during infection. However, the demonstration of a causal relationship in the triggering of autoimmune disease remains to be done. This review provides a synthesis of the PVB19 infection clinical data in adults with a particular focus on these links with autoimmunity.

Oral lesions of viral, bacterial, and fungal diseases in children: A decision tree

Oral mucosal lesions are common in the pediatric population and, apart from traumatic and tumoral etiologies, they can be symptoms of viral, bacterial, fungal or parasitic diseases. Yet, pediatricians and pediatric dentists find it challenging to reach a diagnosis and provide appropriate care when facing lesions of the masticatory or lining mucosa, of the hard or soft palate, of the tongue or salivary glands. Here, we propose a decision tree for the diagnosis of the most frequent viral, bacterial, and fungal diseases starting from their oral lesions in children. By first focusing on describing the elementary lesion itself before its localization and characteristics, it aims to guide the practitioner toward the diagnosis and any necessary complementary exams. To generate this tool, we conducted a literature review of the childhood viral, bacterial, fungal and parasitic diseases with oral mucosal symptoms. For each of the 42 reported diagnoses-20 viral, 9 bacterial, 5 fungal, and 8 parasitic-we collected the infection mechanism and agent(s), the oral lesions and their description, the associated systemic signs and the incidence/prevalence. In fine, our decision tree indexes the 28 diseases for which epidemiological data was available, mainly in Europe and the United States.

A Parsonage-Turner Syndrome secondary to Parvovirus B19 infection

Parvovirus B19 (PVB19) is a small DNA virus that causes the fifth disease in children; however it can also affect adults. The infection can be asymptomatic in about a quarter of healthy subjects. Typical clinical manifestations are: short lived fever accompanied by asthenia, myalgias and pharyngodynia; symmetrical acute polyarthritis; megalo-erytema in child; maculopulotic rash and/or fleeting purpuric at the extremities in adult; adenopathies in the cervical area. Atypical manifestions can affect neurological system (both central and peripheral), hearth and kidney. We describe a 37-year-old man with neuralgic amyotrophy (Parsonage-Turner syndrome) caused by Parvovirus B19 infection.

[Acute erythroblastopenia due to Parvovirus B19 revealing hereditary spherocytosis]

Acute Parvovirus B19 infection is responsible for blocking the erythroblastic line, usually with no consequences on hematopoiesis except in patients with chronic hemolytic anemia in whom it can evolve to potentially serious acute anemia. We report 2 observations of acute erythroblastopenia revealing hereditary spherocytosis in 2 children (1 boy and 1 girl) of non-consanguineous parents.

Vasculite leucocytoclasique compliquée d’une atteinte rénale grave au décours d’une primo-infection à Parvovirus B19

BACKGROUND

Leukocytoclastic vasculitis following Parvovirus B19 primary infection has occasionally been reported in children but it occurs rarely in adults. We present an original case report with severe renal complications.

PATIENTS AND METHODS

A 33-year-old man presented with fever and eruption of the abdomen and members. Papules and vesiculopustules were associated with oral and genital ulcerations. These lesions subsequently became purpuric and necrotic. Histological analysis confirmed the diagnosis of pustulous leukocytoclastic vasculitis with IgA deposits. Laboratory investigations showed elevated sedimentation rate, hepatic cytolysis and renal impairment (hematuria, leucocyturia and proteinuria 1.5 g/24 hours). Anti-parvovirus B19 IgM were positive. Three months after the eruption resolved, IgM were undetectable while anti-parvovirus B19 IgG appeared. Renal injury progressively worsened: elevation of proteinuria (5 g/24 hours) and diminution of creatinine clearance (51 ml/min). Renal biopsy showed glomerulonephritis with mesangial IgA deposits. Major proteinuria persisted one year after the disappearance of dermatological lesions in spite of ACE inhibitor treatment.

DISCUSSION

The role of Parvovirus B19 has been suspected as an aetiological agent in many kinds of vasculitis, e.g. polyarteritis nodosa, Wegener's disease and leucocytoclastic vasculitis. In this case report, the detection of specific IgM and the absence of other factors associated with vasculitis are consistent with a causal role of Parvovirus B19. In previously published cases, the prognosis of parvovirus B19-associated vasculitis does not seem to differ from that of idiopathic vasculitis. To our knowledge, this is the first case exhibiting concomitant and persistent severe renal involvement.

Manifestations systémiques des infections à Parvovirus B19

PURPOSE

Parvovirus B19 (B19) causes many clinical disorders, of which the most common are erythema infectiosum, aplastic crisis complicating chronic hemolytic anemia, and hydrops fetalis. In young adults, the skin eruption caused by B19 is accompanied by polyarthritis and polyarthralgia in 60% of the cases. Rheumatoid factors and other antibodies including antinuclear antibodies, anti-ADN, and antiphospholipids can be produced in the wake of B19 infection.

CURRENT KNOWLEDGE AND KEY POINTS

These features may simulate systemic diseases as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) (lupus-like eruption over the cheeks, cytopenia, etc.) or vasculitis (purpura, renal involvement). In addition, there have been a few reports of SLE, vasculitis and other connective tissue diseases developing shortly after a B19 infection associated with virus clearance suggesting that B19 can act as a trigger of systemic disease. However, studies in large series indicate that in fact B19 is probably an extremely rare cause of RA, SLE or vasculitis.

FUTURE PROSPECTS AND PROJECTS

In fundamental studies B19 interacts with inflammatory cells by regulation of cytokines. More recently, two studies suggest that viral infection due to B19 may affect the course of SLE, leading to specific biological subsets. These preliminary findings require confirmation to elucidate the significance of the presence of B19 in systemic disease.

Parvovirus B19 and autoimmune diseases

Parvovirus B19 (B19) causes many clinical disorders, of which the most common are erythema infectiosum, aplastic crisis complicating chronic hemolytic anemia, and hydrops fetalis. In young adults, the skin eruption caused by B19 is accompanied with polyarthritis and polyarthralgia in 60% of the cases. The joint abnormalities predominate in the hands and feet and usually resolve within a week (range 2-21 d). Serological tests show IgM antibodies against B19, confirming the diagnosis of recent infection. Protracted polyarthritis occurs in some patients and seems associated with the DR4 histocompatibility alleles. Rheumatoid factors can be produced transiently in these patients. Other autoantibodies produced in the wake of B19 infection include anti-nuclear antibodies, anti-DNA, anti-SSA/SSB, and anti-phospholipids. Acute B19 infection can simulate early rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE) (lupus-like eruption over the cheeks, cytopenia, etc.). In addition, there have been a few reports of erosive RA or SLE developing shortly after a B19 infection, with positive PCR tests for B19 DNA in synovial tissue or blood cells. Studies in large series indicate that B19 is probably an extremely rare cause of RA or SLE. Vasculitides affecting the small vessels (Henoch-Schonlein purpura, Wegener's granulomatosis), medium-sized vessels (periarteritis nodosa), and large vessels (giant cell arteritis) can occur after B19 infection. Here again, the number of clinical cases is small.

[Acute transitory intrafamilial erythroblastopenia and hereditary spherocytosis: role of parvovirus B19]

INTRODUCTION

Acute parvovirus B19 infection induces a transient inhibition of erythroid cell formation, which may induce an erythroblastopenia crisis in patients suffering from chronic hemolytic anemia.

EXEGESIS

We report here an exceptional observation of acute erythroblastopenia crisis with good outcome, occurring at the same time in a mother and her son, both suffering from hereditary spherocytosis. Diagnosis of parvovirus infection is based on detection of serum parvovirus B19-specific immunoglobulin M antibodies in the mother and her son and by the positivity of parvovirus B19 DNA detected by PCR in serum in the mother. Outcome was good, with the end of the erythroblastopenia crisis obtained 7 to 10 days later, but requiring blood transfusion in the mother.

CONCLUSION

Our observation is a reminder that the contagiosity of parvovirus B19 is high in household contacts and that protection of family members should rapidly be considered in hereditary spherocytosis.

[Primary parvovirus B19 infection in immunocompetent adults: clinical and biological manifestations. Retrospective study of 16 patients]

PURPOSE

The spectrum of clinical and biological expressions of parvovirus B19 infection is incompletely described.

METHODS

We report 16 retrospective cases of primary parvovirus B19 infection that occurred in immunocompetent adults and were diagnosed by serology.

RESULTS AND CONCLUSION

Most cases conformed to the classical descriptions of parvovirus-induced arthropathy (transient polyarthritis often accompanied by erythema, dysesthesia and pruritus). However, the diagnosis of primary parvovirus B19 infection should also be considered in other clinical and biological situations such as edema, acute anemia or cytopenia, vascular purpura, neuro-ophthalmologic manifestations, and hepatitis. Parvovirus infection may mimic diseases such as lupus erythematosus or systemic necrotizing vasculitis. The risk for confusion with both diseases is increased, as immunological abnormalities such as hypocomplementemia, when they are systematically searched for, prove to be common.