Atraumatic splenic rupture following IVIg for parvovirus B19 pure red cell aplasia post renal transplant

Relapsing anemia associated with parvovirus B19 infection in a kidney transplant recipient: A case report and review of the literature

Key clinical message

PB19 infection should be considered an uncommon cause of posttransplant anemia in renal transplant recipients, particularly those whose anemia is not associated with common etiologies. IVIG treatment and reduced immunosuppression could be beneficial.

Abstract

Parvovirus B19-associated relapsing anemia is rare in kidney transplant recipients. Herein, we report a case of relapsed anemia due to parvovirus B19 infection in a 53-year-old woman 18 months after kidney transplantation. The patient presented with palpitations, shortness of breath, dizziness, weakness, and lethargy. Early laboratory findings showed a WBC count of 6.000/μL, RBC count of 1.89/μL, hemoglobin (Hb) 3.5 g/dL, hematocrit (Hct) 15%, platelet count 266.000/μL, MCV 89, reticulocyte count 0.8%, and serum iron 221 μg/dL. Upon further evaluation, the RT-PCR test for BK polyomavirus and cytomegalovirus (CMV) was negative, while the parvovirus B19 RT-PCR was positive. The patient was treated with blood transfusion and IVIG 25 g daily for 5 days. Two months after discharge, the patient presented, complaining of palpitation, shortness of breath, and dizziness, with RBC 2.7/μL, Hb 6.5 g/dL, Hct 25%, and MCV 85. Again, the CMV RT-PCR was negative, while the parvovirus B19 RT-PCR was positive. Tacrolimus and mycophenolic acid were stopped, and IVIG 25 g daily for 5 days was administered. Consequently, her Hb level increased to 9 g/dL, and the patient was discharged with prednisolone 5 mg daily and cyclosporine 50 mg daily instead of tacrolimus. Viral infection, particularly PB19 infection, should be considered in the differential diagnosis of posttransplantation anemia in KTRs. IVIG treatment and modification of immunosuppressive medications are suggested standard therapies for such patients. The function of transplanted kidneys should be carefully monitored during treatment.

The detection, treatment of parvovirus B19 infection induced anemia in solid organ transplants: a case series and literature review of 194 patients

BACKGROUND

There are no optimal diagnostic, treatment and post-infection surveillance strategies for parvovirus B19 infection in solid organ transplantation (SOT) recipients.

METHODS

We conducted a retrospective review of all PVB19 infected cases confirmed by qPCR among SOT recipients at our institution over a 3-year period and reviewed the literature from 1990 to 2021.

RESULTS

Eight kidney and two heart transplant patients with refractory anemia had PVB19 infection. The viral DNA load in peripheral blood ranged from 2.62 × 10² to 8.31 × 10⁶ copies/mL. Two patients with the lowest PVB19 DNA load only reduced the use of immunosuppressants and anemia was relieved. Eight received intravenous immunoglobulin (IVIG) (ranging from 0.25 to 0.5 g/kg/day). The median time to anemia improvement (hemoglobulin>100g/L) was 16 days (8-70 days) after treatment. One patient had a PVB19 relapse and viral DNA load > 1.00 × 10⁸ copies/mL at diagnosis. A total of 86 studies involving 194 SOTs were screened from the literature, and the most common symptom was anemia and low reticulocyte count. PVB19 DNA was detected in all cases. Of that, 91.4% of cases received IVIG, 53.8% received IVIG and immunosuppression reduction, 6.5% of cases showed reduced immunosuppression without IVIG, and 2.1% did not receive any special treatment. The recurrence rate was 17.5%.

CONCLUSION

PVB19 infection is a cause of anemia after SOT, and treatment mainly relies on IVIG and/or immunosuppression reduction.

Spontaneous splenic hemorrhage in a patient on apixiban

Novel oral anticoagulants (NOACs) are increasingly popular. Spontaneous splenic rupture is rare and life-threatening, especially if it is not immediately recognized. Prior work has demonstrated an association with NOAC use and spontaneous splenic rupture in unusual clinical circumstances. We present the case of spontaneous splenic hemorrhage in a largely healthy 57-year old female who was recently started on apixiban for a provoked PE. She had been discharged from an outside facility, and presented just hours after discharge to our emergency department in extremis: unconscious, pale, hypotensive, and tachycardic. Her abdomen on arrival was noted to be distended with positive fluid wave, and bedside ultrasound confirmed massive peritoneal fluid. Prompt diagnostic peritoneal aspirate confirmed hemoperitoneum, and a massive transfusion protocol was initiated. The patient's blood pressure and heart rate improved, and she was stabilized for imaging. Computed tomography demonstrated large subcapsular splenic hematoma with active extravasation at the periphery of the spleen. The patient was taken emergently to interventional radiology suite where splenic artery embolization was performed and an IVC filter was placed. She subsequently developed acute respiratory distress syndrome and persistent low urine output with hypotension despite resuscitation, and was taken to the operating room for splenectomy and abdominal washout. She improved thereafter and was discharged 12 days later. Prompt diagnosis and aggressive early resuscitation contributed to this patient's outcome.