1
|
Elbadry MI, Khaled SAA, Ahmed NM, Abudeif A, Abdelkareem RM, Ezeldin M, Tawfeek A. Acute human parvovirus B19 infection triggers immune-mediated transient bone marrow failure syndrome, extreme direct hyperbilirubinaemia and acute hepatitis in patients with hereditary haemolytic anaemias: multicentre prospective pathophysiological study. Br J Haematol 2021; 193:827-840. [PMID: 33899219 DOI: 10.1111/bjh.17484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/02/2021] [Indexed: 12/23/2022]
Abstract
A total of 244 patients with hereditary haemolytic anaemias (HHA) were screened for acute symptomatic human parvovirus B19 infection (HPV-B19) in a prospective study. To assess the risks associated with HPV-B19 infection, patients were classified into Group I and Group II according to presence or absence (symptoms, signs and specific serology) of acute HPV-B19 infection respectively. In all, 131 (53·7%) patients had β-thalassaemia, 75 (30·7%) hereditary spherocytosis (HS), 27 (11·1%) sickle cell anaemia (SCA) and 11 (4·5%) glucose-6-phosphate dehydrogenase (G6PD) deficiency. Of 33 (13·5%) patients who presented with symptomatic HPV-B19 infection, 19 (57·5%) had HS, nine (27·3%) had β-thalassaemia and five (15·2%) had SCA. In Group I, there were significant differences in the mean white blood cell, red blood cell and platelet counts, haemoglobin concentration, total bilirubin (TB), alanine aminotransferase, aspartate aminotransferase and serum creatinine (all P < 0·001) compared to Group II. In all, 27 (81·8%) patients had arthropathy and bone marrow failure (BMF); 13 (39·4%) had acute kidney injury (AKI), more in SCA (80%); and 12 (36·4%) patients had hepatitis, more in HS (66·8%). Five (15·2%) patients with HS had BMF, AKI, nervous system involvement and extreme hyperbilirubinaemia (TB range 26·3-84·7 mg/dl). Five (15·2%) patients had haemophagocytic syndrome. Two patients with HS combined with Type-I autoimmune hepatitis presented with transient BMF. Complete recovery or stabilisation was noted at 12 months in every patient except for one patient with SCA who died during the infection. HPV-B19 must be suspected and screened in patients with HHA with typical and atypical presentations with careful follow-up.
Collapse
Affiliation(s)
- Mahmoud I Elbadry
- Department of Internal Medicine, Division of Haematology, Faculty of Medicine, Sohag University, Sohag, Egypt
| | - Safaa A A Khaled
- Department of Internal Medicine-Clinical Haematology Unit, Faculty of Medicine, Assiut University Hospital/Unit of Bone Marrow Transplantation, South Egypt Cancer Institute, Assiut University, Assiut, Egypt
| | - Nesma M Ahmed
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Sohag University, Sohag, Egypt
| | - Ahmed Abudeif
- Tropical Medicine and Gastroenterology Department, Faculty of Medicine, Sohag University, Sohag, Egypt
| | - Rasha M Abdelkareem
- Department of Pathology, Faculty of Medicine, Sohag University, Sohag, Egypt
| | - Mohamed Ezeldin
- Department of Diagnostic and Interventional Radiology, Faculty of Medicine, Sohag University, Sohag, Egypt
| | - Ahmed Tawfeek
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Sohag University, Sohag, Egypt
| |
Collapse
|
2
|
Roy AM, Konda M, Sidarous GK, Atwal D, Schichman SA, Kunthur A. Acquired Amegakaryocytic Thrombocytopenia Misdiagnosed as Immune Thrombocytopenia: A Case Report. Perm J 2021; 24:1-3. [PMID: 33482950 DOI: 10.7812/tpp/19.203] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Acquired amegakaryocytic thrombocytopenia (AATP) is a rare bleeding disorder that causes severe thrombocytopenia with preserved hematopoiesis of other cell lineages. Many cases are misdiagnosed and treated as immune thrombocytopenia. CASE PRESENTATION We report a case of AATP, in a 50-year-old man, that was treated as immune thrombocytopenia for years with no clinical response. The disorder later was diagnosed as AATP after bone marrow biopsy and was successfully treated with cyclosporine. DISCUSSION The exact mechanism of AATP remains unclear; it is suspected to be an immune-mediated process. Patients with AATP present with severe bleeding and thrombocytopenia, which is usually unresponsive to high-dose corticosteroids. There are no standard treatment guidelines for AATP. Cyclosporine and antithymocyte globulin are found to be effective in some cases. The prompt diagnosis of AATP is vital because it carries high mortality because of excessive bleeding, and it can progress into aplastic anemia or myelodysplastic syndrome.
Collapse
Affiliation(s)
- Arya Mariam Roy
- John L McClellan Memorial Veterans Hospital, Little Rock, AR.,University of Arkansas for Medical Sciences, Little Rock, AR
| | - Manojna Konda
- John L McClellan Memorial Veterans Hospital, Little Rock, AR.,University of Arkansas for Medical Sciences, Little Rock, AR
| | - George K Sidarous
- John L McClellan Memorial Veterans Hospital, Little Rock, AR.,University of Arkansas for Medical Sciences, Little Rock, AR
| | - Dinesh Atwal
- John L McClellan Memorial Veterans Hospital, Little Rock, AR.,University of Arkansas for Medical Sciences, Little Rock, AR
| | - Steven A Schichman
- John L McClellan Memorial Veterans Hospital, Little Rock, AR.,University of Arkansas for Medical Sciences, Little Rock, AR
| | - Anuradha Kunthur
- John L McClellan Memorial Veterans Hospital, Little Rock, AR.,University of Arkansas for Medical Sciences, Little Rock, AR
| |
Collapse
|
3
|
Shin H, Park S, Lee GW, Koh EH, Kim HY. Parvovirus B19 infection presenting with neutropenia and thrombocytopenia: Three case reports. Medicine (Baltimore) 2019; 98:e16993. [PMID: 31464949 PMCID: PMC6736112 DOI: 10.1097/md.0000000000016993] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
RATIONALE Parvovirus B19 (PV) infection is usually symptomless and can cause benign, short-lived conditions. Anemia associated with PRCA is the most representative hematologic manifestation, but neutropenia and thrombocytopenia have been rarely reported. PATIENT CONCERNS Three patients were admitted to the hospital with neutropenia and thrombocytopenia. The accompanying symptoms were fever, myalgia, rash, or arthralgia, and all patients were previously healthy. DIAGNOSIS Patients were positive for PV PCR and diagnosed with PV infection. Before the diagnosis of PV infection, 2 patients underwent BM study and almost absence of erythroid progenitor cells in BM aspiration were a clue for the PV infection. Other BM findings were hypocellular marrow and a few hemophagocytic histiocytes. INTERVENTIONS Patients received supportive care with follow-up of CBC. OUTCOMES All 3 patients spontaneously recovered from neutropenia and thrombocytopenia within 3 weeks without severe complications. LESSONS The evaluation of PV infection should be considered in situations where there is neutropenia and thrombocytopenia in healthy individuals even without anemia as a differential diagnosis.
Collapse
Affiliation(s)
| | - Sungwoo Park
- Division of Hematology-Oncology, Department of Internal Medicine Gyeongsang National University Hospital, Gyeongsang National University School of Medicine
| | - Gyeong-Won Lee
- Division of Hematology-Oncology, Department of Internal Medicine Gyeongsang National University Hospital, Gyeongsang National University School of Medicine
- Institute of Health Science, Gyeongsang National University, Jinju
| | - Eun-Ha Koh
- Department of Laboratory Medicine
- Institute of Health Science, Gyeongsang National University, Jinju
| | - Hyun-Young Kim
- Department of Laboratory Medicine & Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| |
Collapse
|
4
|
Kishore J, Kishore D. Clinical impact & pathogenic mechanisms of human parvovirus B19: A multiorgan disease inflictor incognito. Indian J Med Res 2019; 148:373-384. [PMID: 30666000 PMCID: PMC6362725 DOI: 10.4103/ijmr.ijmr_533_18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Human parvovirus B19 (B19V) causes myriads of clinical diseases; however, owing to lack of awareness and undetermined clinical impact, it has failed to become a virus pathogen of global concern. Cryptically, B19V causes significant morbidity and mortality. Half of the world population and 60 per cent of Indians are known to be serologically naive and are at risk of acquiring B19V infections. Cumulatively, our data showed 21.3 per cent B19V-infected patients with juvenile chronic arthropathy, recurrent abortions, multi-transfused thalassaemia and leukaemia. In addition, B19V-infected cases that ended fatally included patients with pure red cell aplasia, fulminant hepatitis and haemophagocytic syndrome. Novel clinical associations of B19V observed were amegakaryocytic thrombocytopaenia, myositis and non-occlusive ischaemic gangrene of bowel. B19V possesses multiple receptors which are distributed widely in human tissues. Vascular endothelial cell infection by B19V causes endothelialitis and vasculitic injuries besides antibody-dependent enhancement which empowered B19V to cause multiorgan diseases. Owing to lack of suitable animal model for B19V, true causal role remains to be determined, but numerous reports on B19V infections substantiate a causal role in multiorgan diseases. Hence, B19V infections need to be recognized, investigated and treated besides making efforts on vaccine developments.
Collapse
Affiliation(s)
- Janak Kishore
- Division of Virology, Department of Microbiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Divya Kishore
- Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi, India
| |
Collapse
|
5
|
Abstract
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.
Collapse
Affiliation(s)
- Jianming Qiu
- Department of Microbiology, Molecular Genetics and Immunology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | - Neal S Young
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| |
Collapse
|
6
|
Kishore J. Real time PCR reconfirmed three novel clinical associations of parvovirus B19: Non-occlusive bowel gangrene, amegakaryocytic thrombocytopenia & myositis. Indian J Med Res 2016; 142:88-9. [PMID: 26261172 PMCID: PMC4557257 DOI: 10.4103/0971-5916.162132] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Affiliation(s)
- Janak Kishore
- Division of Virology, Department of Microbiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226 014, Uttar Pradesh, India
| |
Collapse
|
7
|
Kishore J, Sen M. Parvovirus B19-induced thrombocytopenia and anemia in a child with fatal fulminant hepatic failure coinfected with hepatitis A and E viruses. J Trop Pediatr 2009; 55:335-7. [PMID: 19203989 DOI: 10.1093/tropej/fmp004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A 5-year-old male, drowsy, jaundiced child presented with fulminant hepatitis and had HAV and HEV infection. He had hepatic encephalopathy grade 1, fever, pallor, hypotension, crepitations in his right lung base and hepatosplenomegaly with dyspnoea. He had highly raised liver enzymes and hypoalbuminemia (2.8 g/dl) but anemia (hemoglobin of 7.7 g/dl and 5.7 g/dl 2 days later), reticulocytopenia and severe thrombocytopenia (44 x 10(9)/l) were unexplained. Parvovirus B19-specific IgM antibodies and B19 DNA were found in the serum of the child. Chest X-ray showed pleural effusion and bronchopneumonia, while blood culture isolated coagulase-negative staphylococci (BACTEC 9120) and he had low oxygen saturation. Hence, he was treated with IV amoxicillin+ clavulinic acid and oxygen inhalation. He had seizures and cardiac arrest but was revived. On the third day his condition worsened and the child died despite intensive care. Hence it is concluded that his anemia and thrombocytopenia were B19 induced and this might have aggravated or caused fulminant hepatitis.
Collapse
Affiliation(s)
- Janak Kishore
- Division of Virology, Department of Microbiology, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Lucknow, UP, India.
| | | |
Collapse
|
8
|
Pulanic D, Lozier JN, Pavletic SZ. Thrombocytopenia and hemostatic disorders in chronic graft versus host disease. Bone Marrow Transplant 2009; 44:393-403. [PMID: 19684626 DOI: 10.1038/bmt.2009.196] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Chronic graft versus host disease (cGVHD) is a major and frequent late complication in allogeneic stem cell transplantation recipients. Although thrombocytopenia in cGVHD patients is among the most consistent and strongest predictors of poor survival across many cGVHD studies, such correlation is still neither clearly explained nor well understood. Low platelet counts in the setting of cGVHD are associated with an increase in complications and treatment-related mortality, but usually not with higher relapse rate or engraftment failure rate. Bleeding might be occasionally increased along with, paradoxically, thrombosis. Hemostatic disorders in the context of cGVHD are significant complications with multifactorial etiology, including tissue injury with releasing microparticles, cytokine release, macrophage/monocyte clearance, CMV infection, production of transforming growth factor-beta, and low levels of thrombopoietin. Future clinical trials with agents that stimulate megakaryocytopoiesis or influence underlying impaired hemostasis mechanisms should investigate whether such interventions may improve outcomes in patients with cGVHD.
Collapse
Affiliation(s)
- D Pulanic
- Graft-versus-Host and Autoimmunity Unit, Experimental Transplantation and Immunology Branch, National Cancer Institute, Center for Cancer Research, National Institutes of Health, Bethesda, MD, USA
| | | | | |
Collapse
|
9
|
Weigel-Kelley KA, Yoder MC, Chen L, Srivastava A. Role of integrin cross-regulation in parvovirus B19 targeting. Hum Gene Ther 2006; 17:909-20. [PMID: 16972759 DOI: 10.1089/hum.2006.17.909] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Most viral vectors used for gene therapy lack the ability to target a defined cell population. Parvovirus B19 has a restricted tropism for human erythroid progenitor cells and uses activated alpha5beta1 integrins as coreceptors for entry [Weigel-Kelley, K.A., Yoder, M.C., and Srivastava, A. (2003). Blood 102, 3927-3933]. In this study we examined the role of coexpressed integrins in alpha5beta1 integrin coreceptor function. Antibody-mediated cross-linking of beta1, beta2, and beta3 integrins and the integrin-associated protein (IAP) increased parvovirus B19 entry into nontarget K562 cells. Functional silencing of one integrin group, however, reduced the virus uptake- promoting function of a subsequently activated integrin group, indicating that the three integrins did not operate in isolation but through shared signaling pathways. This was further corroborated by direct competition between simultaneously clustered beta2 and beta1 integrins that could be overcome by stabilizing clustered beta1 integrins in a high-affinity conformation. In contrast, parvovirus B19 entry into primary erythroid progenitor cells was characterized by strong clustering-induced beta1 integrin coreceptor activity that was not abolished by subsequent beta2 and beta3 integrin activation and was, in fact, substantially increased in the presence of preclustered beta2 and beta3 integrins. Thus, integrin function is regulated in a cell type-specific manner through coexpressed integrins and preferential parvovirus B19 entry into erythroid progenitor cells is promoted by a robust beta1 integrin response that is enhanced through stable preclustering of coexpressed integrins. These results have implications for other viral vectors that use integrins as receptors/coreceptors and for gene therapy of hematopoietic progenitor cells using parvovirus B19 vectors.
Collapse
Affiliation(s)
- Kirsten A Weigel-Kelley
- Division of Cellular and Molecular Therapy, Department of Pediatrics, Powell Gene Therapy Center, University of Florida College of Medicine, Gainesville, FL 32610, USA.
| | | | | | | |
Collapse
|
10
|
Weigel-Kelley KA, Yoder MC, Chen L, Srivastava A. Role of Integrin Cross-Regulation in Parvovirus B19 Targeting. Hum Gene Ther 2006. [DOI: 10.1089/hum.2006.17.ft-236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
11
|
Agarwal N, Spahr JE, Werner TL, Newton DL, Rodgers GM. Acquired amegakaryocytic thrombocytopenic purpura. Am J Hematol 2006; 81:132-5. [PMID: 16432869 DOI: 10.1002/ajh.20510] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Acquired amegakaryocytic thrombocytopenia is an unusual hematologic disorder characterized by thrombocytopenia in association with markedly diminished bone marrow megakaryocytes. We report a case that responded to treatment with cyclosporine but not to IL-11. The bone marrow biopsy, repeated after resolution of thrombocytopenia, showed normal number of megakaryocytes.
Collapse
Affiliation(s)
- Neeraj Agarwal
- Division of Hematology, Department of Internal Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah 84132, USA
| | | | | | | | | |
Collapse
|