Rheumatic manifestations of parvovirus B19 infection

Chronic Chikungunya Arthritis and Rheumatoid Arthritis: What They Have in Common

Chikungunya virus (CHIKV) is a single-stranded RNA virus belonging to the family Togaviridae and genus Alphavirus that causes an acute febrile illness, chikungunya fever, which is transmitted to humans by Aedes species mosquitoes. During acute illness, patients have high fever, polyarthralgias or polyarthritis, maculopapular rash, headache, and myalgia that lasts for days to weeks. Following resolution of acute infection, a significant proportion of patients develop chronic chikungunya arthritis that can resemble rheumatoid arthritis. In this review, we first consider the historical background of infectious causes of inflammatory arthritis, and then the pathogenic and clinical manifestations of chronic chikungunya arthritis as a rheumatoid arthritis mimic. We believe that chronic chikungunya arthritis may be a postinfectious inflammatory process, and that an understanding of the parallels and differences between chronic chikungunya arthritis and rheumatoid arthritis may offer insights into better diagnosis and treatment of both diseases.

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CME Rheumatology 20: Parvovirus B19-Induced Tenosynovitis? Abstract. In this case presentation we discuss diagnostic algorithms and differential diagnoses in undifferentiated tenosynovitis. We present a case of a patient with chronic tenosynovitis in the 4th extensor tendon compartment. With unremarkable anamnesis and due to normal laboratory results a «seronegative (RF), ACPA (CCP)-negative tenosynovitis without arthritis» had been reported. Diagnostic and therapeutic tenosynovectomy was performed. Histologic processing revealed a positive PCR for parvovirus B19. We discuss articular and extraarticular manifestations. A parvovirus B19-associated manifestation in the musculoskeletal system is usually self-limiting. The therapy should be carried out symptomatically. In our patient there was a marked local finding, so that the complete tenosynovectomy followed by a single steroid injection led to a persistent restitutio ad integrum.

[Virus-associated arthritis]

Epidemiological studies suggest a viral etiology in approximately 1% of patients presenting with acute arthritis. The arthritogenic effect of viral infections may be related to viral invasion of synovial cells, the cellular and humoral immune response to viral antigens or by induction of autoimmunity. Viral arthritis can mimic rheumatoid arthritis by presenting as a symmetrical polyarticular disease often accompanied by a rash and influenza-like symptoms. Serological testing for pathogen-specific IgM and IgG antibodies is frequently performed for establishing a viral etiology of arthritis. Virus isolation from the joints or detection of viral nucleic acids in the synovium or synovial fluid is only rarely successful and does not always provide proof of a viral origin of arthritis. While viral arthritis in most cases is self-limiting, protracted disease can occur.

Extra-haematological manifestations related to human parvovirus B19 infection: retrospective study in 25 adults

Background

To describe extra-haematological manifestations associated with human parvovirus B19 (HPV-B19) infection.

Methods

We conducted a nationwide multicentre study to retrospectively describe the characteristics and outcome of extra-haematological manifestations in French adults.

Results

Data from 25 patients followed from 2001 to 2016 were analysed. Median age was 37.9 years (range: 22.7–83.4), with a female predominance (sex ratio: 4/1). Only 3 patients had an underlying predisposing condition (hemoglobinopathy or pregnancy). The most common manifestations were joint (80%) and skin (60%) involvement. Four patients (16%) had renal involvement (endocapillary proliferative or membranoproliferative glomerulonephritis, focal segmental glomerulosclerosis). Three patients (12%) had peripheral nervous system involvement (mononeuritis, mononeuritis multiplex, Guillain-Barré syndrome) and 2 (8%) presented muscle involvement. Other manifestations included hemophagocytic lymphohistiocytosis (n = 1), myopericarditis and pleural effusion (n = 1), and lymphadenopathy and splenomegaly mimicking lymphoma with spleen infarcts (n = 1). Immunological abnormalities were frequent (56.5%). At 6 months, all patients were alive, and 54.2% were in complete remission. In 2 patients, joint involvement evolved into rheumatoid arthritis. Six patients (24%) received intravenous immunoglobulin (IVIg), with a good response in the 3 patients with peripheral nervous system involvement.

Conclusions

HPV-B19 infection should be considered in a wide range of clinical manifestations. Although the prognosis is good, IVIg therapy should be discussed in patients with peripheral nerve involvement. However, its efficacy should be further investigated in prospective studies.

Human Parvoviruses

Parvovirus B19 (B19V) and human bocavirus 1 (HBoV1), members of the large Parvoviridae family, are human pathogens responsible for a variety of diseases. For B19V in particular, host features determine disease manifestations. These viruses are prevalent worldwide and are culturable in vitro, and serological and molecular assays are available but require careful interpretation of results. Additional human parvoviruses, including HBoV2 to -4, human parvovirus 4 (PARV4), and human bufavirus (BuV) are also reviewed. The full spectrum of parvovirus disease in humans has yet to be established. Candidate recombinant B19V vaccines have been developed but may not be commercially feasible. We review relevant features of the molecular and cellular biology of these viruses, and the human immune response that they elicit, which have allowed a deep understanding of pathophysiology.

Fever, rash, and systemic symptoms: understanding the role of virus and HLA in severe cutaneous drug allergy

Drug hypersensitivity syndromes such as abacavir hypersensitivity and the severe cutaneous adverse drug reactions have been associated with significant short- and long-term morbidity and mortality. More recently, these immunologically mediated and previously unpredictable diseases have been shown to be associated with primarily class I but also class II HLA alleles. The case of the association of HLA-B*57:01 and abacavir hypersensitivity has created a translational roadmap for how this knowledge can be used in the clinic to prevent severe reactions. Although many hurdles exist to the widespread translation of such HLA screening approaches, our understanding of how drugs interact with the major histocompatibility complex has contributed to the discovery of new models that have provided considerable insights into the immunopathogenesis of severe cutaneous adverse drug reactions and other T-cell-mediated drug hypersensitivity syndromes. Future translation of this knowledge will facilitate the development of preclinical toxicity screening to significantly improve efficacy and safety of drug development and design.

Human parvovirus B19 infection mimicking systemic lupus erythematosus

Abstract Although several recent reports have discussed the similarities between human parvovirus B19 (HPV-B19) infection and systemic lupus erythematosus (SLE), the relationship between these conditions has not been established owing to the small number of patients investigated. In 1998-1999, an outbreak of Erythema infectiosum occurred close to our hospital, enabling us to investigate the clinical, hematological, and serological findings, including serum complement and antinuclear antibodies (ANA), in 22 patients with acute HPV-B19 infection. The principal symptoms included rash (86.3%), edema (59%), arthralgia (45.4%) and fever (31.8%). Lymphadenopathy was seen in three of the 22 cases. The laboratory findings showed high incidences of leukopenia (50%), hypocomplementemia (95%), and ANA (64.7%). At the time of disease onset, patients with acute HPV-B19 infection presented with features which were similar to those of SLE. The possibility of HPV-B19 infection should therefore be considered in patients presenting with SLE-like features.

A guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2013 recommendations by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM)(a)

The critical role of the microbiology laboratory in infectious disease diagnosis calls for a close, positive working relationship between the physician and the microbiologists who provide enormous value to the health care team. This document, developed by both laboratory and clinical experts, provides information on which tests are valuable and in which contexts, and on tests that add little or no value for diagnostic decisions. Sections are divided into anatomic systems, including Bloodstream Infections and Infections of the Cardiovascular System, Central Nervous System Infections, Ocular Infections, Soft Tissue Infections of the Head and Neck, Upper Respiratory Infections, Lower Respiratory Tract infections, Infections of the Gastrointestinal Tract, Intraabdominal Infections, Bone and Joint Infections, Urinary Tract Infections, Genital Infections, and Skin and Soft Tissue Infections; or into etiologic agent groups, including Tickborne Infections, Viral Syndromes, and Blood and Tissue Parasite Infections. Each section contains introductory concepts, a summary of key points, and detailed tables that list suspected agents; the most reliable tests to order; the samples (and volumes) to collect in order of preference; specimen transport devices, procedures, times, and temperatures; and detailed notes on specific issues regarding the test methods, such as when tests are likely to require a specialized laboratory or have prolonged turnaround times. There is redundancy among the tables and sections, as many agents and assay choices overlap. The document is intended to serve as a reference to guide physicians in choosing tests that will aid them to diagnose infectious diseases in their patients.

The role of human xanthine oxidoreductase (HXOR), anti-HXOR antibodies, and microorganisms in synovial fluid of patients with joint inflammation

This work is to investigate the levels of human xanthine oxidoreductase (HXOR), its antibodies, and microorganisms in synovial fluid of patients with untreated rheumatoid joint diseases. Synovial fluids were collected from sixty-four patients with rheumatoid joint diseases. Sixty-four age-matched individuals were included as control. Xanthine oxidoreductase (XOR) proteins level and anti-XOR antibodies were determined in the blood and synovial fluid, using human XOR as antigen, by enzyme-linked immunosorbent (ELISA) assay. Synovial fluids were cultured for bacteria and fungi. The titers of XOR protein in the synovial fluid of patients with rheumatoid arthritis were 90.43 ± 23.37 μg/ml (mean ± SD, n = 29) and up to 62.42 ± 8.74 μg/ml (mean ± SD, n = 35) in other joint inflammation. Anti-HXOR antibodies titers in patients were 167.72 ± 23.64 μg/ml, n = 64, which was significantly higher in rheumatoid arthritis patients. The results indicated that anti-HXOR antibodies in synovial fluids have a protective role as high concentrations against XOR were detected in inflammatory arthritis. These antibodies play a role in eliminating XOR from synovial fluids. However, immune complex formation could activate complement and participate in propagating the inflammatory cycle. Synovial aspirate ordinary microbial cultures were negative for any bacteria or fungi, but that does not exclude organisms of special culture requirements.

Parvovirus B19 infection in human pregnancy

Human parvovirus B19 infection is widespread. Approximately 30-50% of pregnant women are nonimmune, and vertical transmission is common following maternal infection in pregnancy. Fetal infection may be associated with a normal outcome, but fetal death may also occur without ultrasound evidence of infectious sequelae. B19 infection should be considered in any case of nonimmune hydrops. Diagnosis is mainly through serology and polymerase chain reaction. Surveillance requires sequential ultrasound and Doppler screening for signs of fetal anaemia, heart failure and hydrops. Immunoglobulins, antiviral and vaccination are not yet available, but intrauterine transfusion in selected cases can be life saving.

Parvovirus B19 induced hepatic failure in an adult requiring liver transplantation

Parvovirus B19 induced acute hepatitis and hepatic failure have been previously reported, mainly in children. Very few cases of parvovirus induced hepatic failure have been reported in adults and fewer still have required liver transplantation. We report the case of a 55-year-old immunocompetent woman who developed fulminant hepatic failure after acute infection with Parvovirus B19 who subsequently underwent orthotopic liver transplantation. This is believed to be the first reported case in the literature in which an adult patient with fulminant hepatic failure associated with acute parvovirus B19 infection and without hematologic abnormalities has been identified prior to undergoing liver transplantation. This case suggests that Parvovirus B19 induced liver disease can affect adults, can occur in the absence of hematologic abnormalities and can be severe enough to require liver transplantation.

Parvovirus B19: its role in chronic arthritis

B19 infection-associated joint symptoms occur most frequently in adults, usually presenting as a self-limited, acute symmetric polyarthritis affecting the small joints of the hands, wrists, and knees. A small percentage of patients persist with chronic polyarthritis that mimics rheumatoid arthritis raising the question of whether B19 virus may have a role as a concomitant or precipitating factor in the pathogenesis of autoimmune conditions. Comprehensive and updated reviews address different aspects of human parvovirus infection. This article focuses on the evidence supporting the arthritogenic potential of the B19 virus and the proposed mechanisms that underlie it.

Persistent parvovirus B19 infection and arthralgia in a patient mistakenly treated for Lyme disease

We report a case of a 37-year-old woman with persistent parvovirus B19 infection and arthralgia mistakenly treated for Lyme disease. This case indicates that poor standardization of both screening and confirmatory assays for Lyme disease can lead to an incorrect diagnosis of Lyme disease. Before making a final diagnosis of Lyme arthritis in an endemic region, other causative agents of arthritis, such as parvovirus B19, should be excluded to avoid unnecessary treatment or to add appropriate therapy in the case of co-infections. Since parvovirus B19 is often associated with arthralgia and can mimic rheumatoid arthritis and autoimmune diseases, it should be included in the differential diagnosis of arthralgia.

Fatal parvoviral myocarditis: a case report and review of literature

Background

Histologically documented cases of parvoviral myocarditis are exceedingly rare.

Case presentation

Here, we report a 41-year old African American immunocompetent patient who died of parvoviral myocarditis after a 10 day illness characterized by fever, headaches, generalized arthralgias, and a maculopapular rash.

Autopsy revealed an infiltrate myocarditis composed primarily of T-lymphocytes and macrophages associated with extensive myocardial fibrosis. The diagnosis of parvovirus was determined by polymerase chain reaction (PCR) on both pre-mortem serum and post-mortem myocardial tissue

Methods

DNA was extracted from tissue and serum and primers were used to amplify DNAsequences of parvovirus B19 using nested polymerase chain reaction (PCR).

Conclusion

The diagnosis of parvovirus should be considered in cases of fatal myocarditis, and diagnosis can be confirmed at autopsy by molecular techniques.

Outcome of patients with arthritis and parvovirus B19 DNA in synovial membranes

To investigate the follow-up of the 17 patients during the period of 1995-2001 of the outpatient Clinic for Rheumatology at the University Hospital of Zurich with arthritis and the presence of parvovirus B19 DNA demonstrated by PCR in synovial biopsies. Seventeen patients of 163 with arthritis, which were routinely examined by needle arthroscopy during 1995-2001 with a positive parvovirus B19 DNA by PCR of synovial biopsy were reevaluated. Investigations included medical history, clinical examination and blood tests. Joint fluid was taken on patients with joint effusion. The observation period of the 17 patients (F:M = 11:6) was 2-8 years (Ø = 6.5 years). In 8 of 17 patients the arthritis could not be classified neither at entry nor during the follow up of the study. The arthritis could be diagnosed in six patients early in the onset of the disease and included three cases of lyme arthritis of the knee joint, two cases with arthritis following a gastrointestinal infection (one with Salmonella typhimurium--positive faecal test--and the other one with a culture negative agent), one patient probably had an infection-associated arthritis after a gastrointestinal infection with Entamöeba histolytica (Schirmer et al. in Rheumatol Int 18:37-38, 1998; Kasliwal in Am J Proctol Gastroenterol Colon Rectal Surg 32:12, 16, 28, 1981; Haslock and Wright in J R Coll Phys Lond 8:1554-162, 1974; Than-Saw et al. in Trop Geogr Med 44:355-358, 1992) with remission after antibiotic therapy. After a disease course of 9 months one patient could be classified as rheumatoid arthritis in the presence of anti-cyclic citrullinated antibodies but lack of rheumatoid factor. One patient with polyarthritis developed psoriasis of the skin 22 months later. From the nine patients with unclassified arthritis 4 (45%) got into complete remission with no symptoms or signs of joint inflammation after a disease course of 9-45 months, whereas 5 (55%) still demonstrate active non erosive arthritis (disease duration between 3 and 10 years). The presence of parvovirus B19 DNA in synovial tissue of patients with joint inflammation does not allow the diagnosis of parvovirus induced arthritis. If the arthritis remains unclassified and without erosions over time a virus associated aetiology may be assumed. However, no definitive diagnosis is possible even in the presence of parvovirus B19 DNA in synovial tissue.

Unscrambling the role of human parvovirus B19 signaling in systemic autoimmunity

Despite enormous progress in understanding how the immune system works, the pathogenesis of autoimmune diseases still remains unclear. Growing evidence indicates that infectious agents can be potent initial triggers, subverting and exploiting host cell signaling pathways. This role is exemplified by the association of parvovirus B19 (B19) with human autoimmune disease. Infection with this common virus exhibits striking similarities with systemic autoimmune diseases, and can be associated with elevated serum autoantibody titers. The B19 virus produces proline-rich, 11-kDa proteins that have been implicated in modulation of host signaling cascades involved in virulence and pathogenesis. Additionally, B19 produces a non-structural protein (NS1) that functions as a transcription regulator by directly binding the p6 promoter and the Sp1/Sp3 transcription factors. The protein is also involved in DNA replication, cell cycle arrest and initiation of apoptotic damage, particularly in erythroid cells. When transfected to non-permissive cells, NS1 recruits the mitochondria cell death pathway. It is even more remarkable that NS1 functions as a trans-acting transcription activator for the IL6 promoter, up-regulating IL6 expression in host cells. Hence, B19 infection may play a pivotal role in triggering inflammatory disorders. By promoting apoptotic damage and trans-activating pro-inflammatory cytokine promoters, B19 may break the delicate balance between cell survival and apoptosis, and may contribute to immune deregulation. Understanding the mechanisms used by B19 to alter the cell signaling machinery may provide further insight into the mechanism by which autoimmune diseases develop.

Clinical aspects of parvovirus B19 infection

Parvovirus B19 is a significant human pathogen that causes a wide spectrum of clinical complications ranging from mild, self-limiting erythema infectiosum in immunocompetent children to lethal cytopenias in immunocompromised patients and intrauterine foetal death in primary infected pregnant women. The infection may also be persistent and can mimic or trigger autoimmune inflammatory disorders. Another important clinical aspect to consider is the risk of infection through B19-contaminated blood products. Recent advances in diagnosis and pathogenesis, new insights in the cellular immune response and newly discovered genotypes of human parvoviruses form a platform for the development of modern therapeutic and prophylactic alternatives.

Epstein-Barr virus and rheumatoid arthritis: is there a link?

Rheumatoid arthritis is a systemic autoimmune disease characterized by chronic, destructive, debilitating arthritis. Its etiology is unknown; it is presumed that environmental factors trigger development in the genetically predisposed. Epstein–Barr virus, a nearly ubiquitous virus in the human population, has generated great interest as a potential trigger. This virus stimulates polyclonal lymphocyte expansion and persists within B lymphocytes for the host's life, inhibited from reactivating by the immune response. In latent and replicating forms, it has immunomodulating actions that could play a role in the development of this autoimmune disease. The evidence linking Epstein–Barr virus and rheumatoid arthritis is reviewed.

A case of persistent parvovirus B19 infection with bilateral cartilaginous and ligamentous damage to the wrists

We describe a case of persistent parvovirus B19 infection in a 48-year-old female physician that was complicated by prolonged fatigue and arthritis associated with cartilaginous and ligamentous damage in both wrists. Nineteen months after presentation, intravenous immunoglobulin therapy resulted in clearance of parvovirus B19 viremia and a significant improvement in the symptoms of fatigue and arthritis.

Parvoviral infection of endothelial cells and stromal fibroblasts: a possible pathogenetic role in scleroderma

BACKGROUND

Systemic sclerosis (SSc) is a connective tissue disease (CTD) which differs from other CTDs by progressive irreversible fibrosis in lung, kidney, skin, and heart. It has a worse prognosis compared to several other CTDs. The pathogenesis may reflect a humorally mediated microangiopathy in concert with the overproduction of collagen triggered by immune-mediated cytokine production. Having previously demonstrated parvovirus B19 (B19) DNA in bone marrow and skin biopsies of SSc patients in the absence of B19 viremia, we sought to further elucidate a role for B19 in the pathogenesis of SSc.

DESIGN

Twelve patients who fulfilled American College of Rheumatology criteria for a diagnosis of SSc were encountered. Ten were serologically screened for B19 infection. Solution phase polymerase chain reaction (PCR) for B19 DNA was performed on skin tissue from six patients, and in all biopsies, reverse transcriptase in situ PCR (RT in situ PCR) for B19 and tumor necrosis factor (TNF)-alpha mRNA was performed. B19 viral protein (VP2) expression was sought by immunohistochemistry and correlated to PCR findings and to light microscopy of hematoxylin and eosin-stained sections. Frozen tissue was also available on five of the patients. Two control groups were assessed for B19 and TNF expression comprising one with irrelevant primers and the other representing 18 cases of inflammatory skin lesions where the etiology was known and unrelated to B19 infection. In addition, frozen and paraffin-embedded tissues procured from skin lesions unrelated to B19 infection were assessed for B19 genome. In all cases, pretreatment with RNase was also performed to verify that any positive signal was indeed RNA based.

RESULTS

Diffuse SSc was seen in seven patients, and limited disease in five. All patients had an antinuclear antibody--specifically, an antinucleolar, anticentromere, and/or anti-Scl 70 antibody. Eleven of the 12 had lung involvement, whereas eight patients had myocardial disease. Of 12 patients tested serologically, nine had B19-specific antibodies, which included immunoglobulin M (IgM)-specific antibodies in two cases. Solution phase PCR showed B19 DNA in the skin in three cases and in the bone marrow in three cases, including two in whom skin-based B19 DNA was observed. In all cases, RT in situ PCR demonstrated B19 and TNF-alpha mRNA in endothelia, fibroblasts, mast cells, and perivascular inflammatory cells. Immunohistochemistry to assess VP2 was either negative or equivocal. Immunofluorescent studies revealed prominent deposition of C5b-9 within the cutaneous vasculature from biopsies of all patients tested. The control samples were negative for B19 and TNF RNA and DNA.

CONCLUSIONS

Parasitism of endothelia and fibroblasts by B19 with resultant enhanced TNF-alpha expression may be of pathogenetic importance in SSc even in the absence of demonstrable viremia. The vascular deposition of C5b-9 suggests a role for humoral immunity possibly induced by a state of endothelial neoantigenicity evoked by virally mediated cell injury. Treatment strategies include anti-viral therapy, including in the context of intravenous gamma-globulin and anti-TNF therapy.

Parvovirus B19-related chronic monoarthritis: immunohistochemical detection of virus-positive lymphocytes within the synovial tissue compartment: Two reported cases

Apart from systemic symptoms of viral infection parvovirus B19, the infectious agent in erythema infectiosum, can lead to mainly self-limited acute and chronic arthropathy. Because mild subclinical features of the disease can be easily overlooked, joint affections might appear as isolated symptoms. We here report two cases of chronic monoarthritic symptoms of unknown origin, where immunohistochemical detection of B19-positive lymphocytic cells in the synovial tissue led to the diagnosis of B19 arthropathy. In conclusion, respective virus diagnostics should be considered even in chronic monosymptomatic arthritic lesions. The pathology of B19 arthropathy seems to be due to direct virus infection of cells within the synovia.

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.

Papular purpuric rash due to parvovirus B19 with distribution on the distal extremities and the face

We describe 3 patients who presented with a distinctive clinical picture of the purpuric rash called "gloves-and-socks syndrome" which was characterized by an acral distribution of the rash that involved not only the distal part of the extremities but also the chin and perioral area. Serologic analysis for parvovirus B19 yielded positive results. Parvovirus B19 should be included in the evaluation of febrile purpura.

Presence of parvovirus B19 DNA in chronic urticaric and healthy human skin

BACKGROUND

The etiology of chronic urticaria is undefined, but the potential role of infectious agents as one triggering factor has been suggested. The appearance of chronic urticaria in a 16-year old male after a history of a recent parvovirus B19 (B19) infection led us to investigate the association between B19 and chronic urticaria.

OBJECTIVES

To investigate whether parvovirus B19 (B19) has a role in chronic urticaria.

STUDY DESIGN

We amplified B19 DNA from skin biopsy samples of 36 adult chronic urticaria patients as well as of 22 healthy controls using two sets of separate primers and probe. Circulating IgG and IgM antibodies to B19 were measured from 27 patients and from all controls.

RESULTS

B19 DNA was detected in 18 (50%) skin biopsy samples of 36 patients with chronic urticaria. Unexpectedly, also 14 (64%) skin biopsy samples from 22 healthy controls harbored B19 DNA. All 32 persons with positive B19 PCR findings had circulating IgG-class antibodies to B19 major structural protein VP2, but no IgM antibodies.

CONCLUSION

Our results show that B19 DNA commonly exists in human skin. Therefore, the association between B19 infection and chronic urticaria remains uncertain. However, these findings raise the question whether the skin may constitute a reservoir for B19.

Detection of human parvovirus B19 infection: a study of 212 suspected cases in the state of Rio de Janeiro, Brazil

BACKGROUND

Parvovirus B19 infections are associated with different clinical manifestations that vary from symptom-less to severe. The main clinical manifestations are erythema infectiosum or fifth disease, transient aplastic crisis in individuals with hemoglobinopathies, chronic anemia in the immunocompromised, acute polyarthralgia syndrome in adults, hydrops fetalis, spontaneous abortion and stillbirth. Although the classical features of B19 and rubella infections are distinct, uncommon presentations can lead to misdiagnosis.

OBJECTIVE

The goal of this study was to assess the occurrence of parvovirus B19 (B19) infection in patients with clinical signs of toxoplasmosis or rubella, both of which were not confirmed by laboratorial techniques.

STUDY DESIGN

Serum samples from 214 patients were collected between January 1996 and December 1997 in the state of Rio de Janeiro, Brazil, B19 specific IgG and IgM were detected by using commercial enzyme-linked immunosorbent assays (ELISA), and viral nucleic acid was detected employing a nested polymerase chain reaction (PCR) protocol.

RESULTS

Combining the results obtained by IgM ELISA and PCR, 14.5% of the samples were positive in one or both tests, with a concordance of 92.5% between the two techniques.

CONCLUSIONS

Specimens collected in 16 out of 22 municipalities were positive in at least one out of the three tests employed, indicating that parvovirus B19 circulates in several regions of the state of Rio de Janeiro.

Human parvovirus B19

Parvovirus B19 (B19) was discovered in 1974 and is the only member of the family Parvoviridae known to be pathogenic in humans. Despite the inability to propagate the virus in cell cultures, much has been learned about the pathophysiology of this virus, including the identification of the cellular receptor (P antigen), and the control of the virus by the immune system. B19 is widespread, and manifestations of infection vary with the immunologic and hematologic status of the host. In healthy immunocompetent individuals B19 is the cause of erythema infectiosum and, particularly in adults, acute symmetric polyarthropathy. Due to the tropism of B19 to erythroid progenitor cells, infection in individuals with an underlying hemolytic disorder causes transient aplastic crisis. In the immunocompromised host persistent B19 infection is manifested as pure red cell aplasia and chronic anemia. Likewise, the immature immune response of the fetus may render it susceptible to infection, leading to fetal death in utero, hydrops fetalis, or development of congenital anemia. B19 has also been suggested as the causative agent in a variety of clinical syndromes, but given the common nature, causality is often difficult to infer. Diagnosis is primarily based on detection of specific antibodies by enzyme-linked immunosorbent assay or detection of viral DNA by dot blot hybridization or PCR. Treatment of persistent infection with immunoglobulin reduces the viral load and results in a marked resolution of anemia. Vaccine phase I trials show promising results.

Induction of an invasive phenotype by human parvovirus B19 in normal human synovial fibroblasts

OBJECTIVE

To investigate the possible role of human parvovirus B19 as an etiologic agent in rheumatoid arthritis (RA), with particular emphasis on its ability to induce invasiveness in human synovial fibroblasts.

METHODS

We established an experimental in vitro system in which normal primary human synovial fibroblasts were treated with or without parvovirus B19-containing human sera for 7 days. The fibroblasts were then tested for their ability to degrade reconstituted cartilage matrix using a well-characterized cartilage invasion assay system.

RESULTS

Incubation with parvovirus B19-containing serum induced an invasive phenotype in normal human synovial fibroblasts. B19 serum-treated synovial fibroblasts exhibited an increase in invasion of up to 248% compared with the activity of fibroblasts in media alone, in contrast to B19-negative sera-treated synovial fibroblasts, which exhibited no significant change compared with that in media alone. In addition, preincubation of viremic serum with a neutralizing antibody to B19 abrogated the observed effect.

CONCLUSION

These results provide direct evidence regarding the ability of parvovirus B19 to induce invasive properties in normal human synovial fibroblasts. Parvovirus B19 has been proposed as an etiologic agent of RA, and our data provide the first biologic link between exposure to B19 and phenotypic changes in normal human synovial fibroblasts.

Parvovirus B19 infection associated with the production of anti-neutrophil cytoplasmic antibody (ANCA) and anticardiolipin antibody (aCL)

We described four patients who had clinical diagnosis of erythema infectiosum and presented with skin rash, polyarthralgia, polyarthritis, and mild fever. Anti-parvovirus B19 IgM and IgG antibodies were found in all four patients and parvovirus B19 DNA was detected in three of the four patients by polymerase chain reaction (PCR) in sera using standard methods. Anticardiolipin antibody (aCL) was positive in three of the four patients included three with anti-beta2 glycoprotein I (beta2GPI). The immunoglobulin isotype of aCL was found to be IgM. Anti-neutrophil cytoplasmic antibody (ANCA) included three p-ANCA and one c-ANCA was detected in all four patients by indirect immunofluoresence (IIF). Both anti-proteinase 3 (PR3) and anti-myeloperoxidase (MPO) antibodies were found in two patients whom had polyarthritis for more than 6 months. These data indicate parvovirus B19 may be linked to the induction of an autoimmune response.

Parvovirus-associated arthritis

Human parvovirus B19 is the cause of several distinct clinical syndromes. The most common is erythema infectiosum (fifth disease), a febrile exanthem occurring primarily in children. Recent studies have shown that parvovirus B19 can cause acute arthritis and occasionally a chronic arthropathy, both in children and adults. Parvovirus B19 DNA has been detected in studies in the synovial tissue of patients with rheumatoid arthritis, but other studies have varied in their findings. Recent studies also indicate a possible connective tissue disease-like syndrome with parvoviral infections. The common features of this syndrome are malar eruption, arthralgias, arthritis, and laboratory abnormalities including antinuclear antibody and rheumatoid factor positivity. However, the data indicate it is unlikely that B19 infection causes rheumatoid arthritis or systemic lupus erythematosus. Continued studies of the pathogenesis of acute and chronic parvoviral B19 infections and arthropathy may provide insights into virus-host interactions and mechanisms of joint disease and connective tissue disease.

Raynaud's phenomenon as a manifestation of parvovirus B19 infection: case reports and review of parvovirus B19 rheumatic and vasculitic syndromes

Infection with human parvovirus B19 is manifested as erythema infectiosum, transient aplastic crisis, or hydrops fetalis. Rheumatic manifestations include arthropathy and various vasculitic syndromes. Isolated Raynaud's phenomenon due to parvovirus B19 has never been described. We report on 2 previously healthy sisters with new-onset Raynaud's phenomenon accompanied by severe generalized polyarthralgia. A full workup was negative, except serology for parvovirus B19, which was positive. All symptoms gradually subsided within 3-5 months, and no recurrence has been noted during the 3 years since onset. We review all the studies in the English-language literature on parvovirus B19-induced rheumatic and vasculitic syndromes. We hypothesize that the pathogenesis of Raynaud's phenomenon in our patients involved immune-mediated endothelial damage leading to platelet activation and vasoconstriction. We recommend that in cases of unexplained Raynaud's phenomenon, serology for parvovirus B19 be included in the evaluation.

Infection with Parvovirus B19

Human parvovirus B19 is common and widespread. Major manifestations of B19 infection are transient aplastic crisis, erythema infectiosum, hydrops fetalis, acute and chronic rheumatoid-like arthropathy and, in the immunocompromised host, chronic or recurrent bone marrow infection. Less common presentations include skin eruptions, isolated cytopenias, vasculitis, hepatitis, and neuropathies. Increasing awareness of the clinical manifestations of B19 infection makes parvovirus B19 an emerging virus. B19 may persist in healthy or immunocompromised individuals. B19 has been suggested as a candidate agent in rheumatic diseases.