Association of parvovirus B19 infection with acute glomerulonephritis in healthy adults: case report and review of the literature

[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.

Parvovirus leading to thrombotic microangiopathy in a healthy adult

A healthy 47-year-old man initially presented with symptoms of body rash, myalgias, dark urine, nausea and vomiting. Acute kidney injury, and positive urine analysis for blood and protein warranted a kidney biopsy, which revealed micro thrombi in kidney vasculature, suggestive of thrombotic microangiopathy. Serology revealed positive parvovirus B19 IgM antibodies and biopsy tests revealed a viral genome on PCR. Despite plasma exchanges and treatment with rituximab, renal function continued to deteriorate to end-stage renal disease.

Practice parameter for the diagnosis and management of primary immunodeficiency

The American Academy of Allergy, Asthma & Immunology (AAAAI) and the American College of Allergy, Asthma & Immunology (ACAAI) have jointly accepted responsibility for establishing the "Practice parameter for the diagnosis and management of primary immunodeficiency." This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma & Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion.

Clinical investigation of human parvovirus B19 infection after renal transplantation in China

OBJECTIVE

We investigated the incidence of human parvovirus B19 (HPV B19) infection after renal transplantation as well as the risk of anemia and renal allograft damage among infected transplant recipients in China.

METHODS

We selected 114 patients at 1-18 months after renal transplantation for detection of HPV B19 DNA copies compared with a control population. Renal function and hematopoiesis were compared between infected and noninfected groups.

RESULTS

Twenty-seven patients diagnosed with HPV B19 infection during follow-up (18.75%),which was a significantly higher number than among the general population over the same period. Infected versus nonaffected patients exhibited a significantly higher incidence of anemia and urinary abnormalities in addition to significantly lower values of hemoglobin, higher serum creatinine concentrations, and lower glomerular filtration rates. The 2 groups did not differ in the types or doses of calcineurin inhibitor (CNI) immunosuppressants. Two cases of pure red cell aplasia (PRCA) as confirmed using bone marrow biopsy, were observed in the infected group. They displayed HPV B19 DNA copy numbers >10(7)/mL and segmental mesangial cell proliferation on renal biopsy. The PRCA cases were cured with immunomodulatory therapy.

CONCLUSIONS

The HPV B19 infection rate was significantly higher among renal transplant recipients than normal controls. Infections correlated with damage to the renal allograft, which may in turn cause PRCA. Immunomodulation therapy was effective to treat this complication of HPV B19 infection.

[Parvovirus B19 infection after kidney transplantation]

Prevalence for human parvovirus B19 infection is estimated to be between 2% and 30% in renal transplant recipients. In post-transplant settings, parvovirus B19 infection may occur either as a primary infection or a reactivation. Parvovirus transmission most commonly occurs through respiratory tract but may also result from graft or blood packs contamination. Co-infections with HHV-6 and CMV viruses are frequent. The hallmark symptom is anemia, more rarely pancytopenia and hemophagocytic syndrome. In respect to renal involvement, parvovirus B19 infection has been associated with graft dysfunction in 10% of cases. Both thrombotic microangiopathies and collapsing glomerulopathies have been reported concomitantly with parvovirus B19 infection but the causal link remains unclear. Other complications are seldomly reported, including hepatitis, encephalitis, and myocarditis. Diagnosis is based on pre and post-transplant serological status. In addition, the management of parvovirus B19 infection in immunocompromised patients requires quantitative assessment of blood viral load by PCR. The treatment relies primarily on reduction of immunosuppression combined with intravenous immunoglobulin infusions. Relapses occur in 30% of cases.

Pregnancy-associated parvovirus B19 infection causing postinfectious glomerulonephritis

BACKGROUND

Postinfectious glomerulonephritis due to parvovirus B19 during pregnancy is not described in the literature.

OBJECTIVE

A case and renal biopsy of postinfectious glomerulonephritis due to parvovirus B19 during pregnancy is presented.

DISCUSSION AND CONCLUSIONS

The patient contracted "fifth disease," parvovirus B19, in the 10th week of pregnancy, and 2 weeks later developed hypertension, nephrotic range proteinuria, pleural effusions, and evidence of pure red cell aplasia. Serum parvovirus B19 IgM was positive; a renal biopsy was performed, revealing diffuse proliferative glomerulonephritis with immunofluorescent and electron microscopic changes consistent with postinfectious glomerulonephritis. Renal, hemodynamical, and hematological parameters returned to normal by the 16th week gestation, and the pregnancy proceeded without further complication to the mother, with term delivery of a healthy infant.

[Various clinical symptoms in human parvovirus B19 infection]

Human parvovirus B19 infection causes erythema infectiosum in child, aplastic crisis in patients with chronic hemolytic anemia, chronic pure red cell aplasia in immunocompromised patients and hydrops fetalis. Human parvovirus B19 causes arthritis and acute glomerulonephritis due to immunological mechanism. Other disorders, rheumatoid arthritis, vasculitis and thrombotic microangiopathy, are linked in human parvovirus B19 infection. Parvovirus B19 infection causes choronic rheumatoid-like arthropathy. Autoantibody and low complement were seen in acute human parvovirus infection, and parvovirus B19 infection present clinically lupus like tableau.

Socks but no gloves

A 38-year-old female suffered from acute parvovirus B19 infection which was complicated by profound peripheral lower limb edema but no purpuric exanthemata. The pathophysiology of edema in parvovirus infection remains to be accurately defined.

Parvovirus-B19-associated complications in renal transplant recipients

Parvovirus B19 is a common human pathogen, causing erythema infectiosum in children, hydrops fetalis in pregnant women, and transient aplastic crisis in patients with chronic hemolytic anemia. Immunosuppressed patients can fail to mount an effective immune response to B19, resulting in prolonged or persistent viremia. Renal transplant recipients can develop symptomatic B19 infections as a result of primary infection acquired via the usual respiratory route or via the transplanted organ, or because of reactivation of latent or persistent viral infection. The most common manifestations of B19 infection in immunosuppressed patients are pure red cell aplasia and other cytopenias. Thus, this diagnosis should be considered in transplant recipients with unexplained anemia and reticulocytopenia or pancytopenia. Collapsing glomerulopathy and thrombotic microangiopathy have been reported in association with B19 infection in renal transplant recipients, but a causal relationship has not been definitively established. Prompt diagnosis of B19 infection in the renal transplant recipient requires a high index of suspicion and careful selection of diagnostic tests, which include serologies and polymerase chain reaction. Most patients benefit from intravenous immunoglobulin therapy and/or alteration or reduction of immunosuppressive therapy. Conservative therapy might be sufficient in some cases.

Parvovirus B19 and the kidney

Infection with parvovirus B19 causes several clinical syndromes (fifth disease, transient aplastic crisis, pure red cell aplasia, and hydrops fetalis) and may contribute to other illnesses. B19 has been linked to renal disease in three settings: As a cause of acute glomerulopathy and as a cause of anemia in ESRD and kidney transplantation. Case reports implicate parvovirus in the pathogenesis of proliferative glomerulonephritis and collapsing glomerulopathy, but a causal relationship has not been established. A proposed role for B19 infection is based on the temporal association of renal findings with viral infection, positive serology, and identification of the viral genome in the glomerulus. Mechanisms may include cytopathic effects on glomerular epithelial cells and/or endothelial cells and glomerular deposition of immune complexes. Patients who require dialysis may have increased susceptibility to acute and chronic anemia after parvoviral infection. Factors that predispose this population to complications of B19 infection include impaired immune response, deficient erythropoietin production, and possibly decreased erythrocyte survival. The clinical burden of parvovirus B19 infection in renal transplant recipients may be underestimated; these individuals may develop persistent viremia as a result of a dysfunctional immune response. Chronic anemia and pure red blood cell aplasia are the most common complications of parvovirus infection in this population; the diagnosis should be considered in transplant recipients with unexplained anemia or pancytopenia. Allograft rejection and dysfunction have been reported in association with infection, but a cause-effect relationship has not been proved. Further investigation of the relationship between B19 and kidney disease is warranted.

Glomerulonephritis associating parvovirus B19 infection

We report a previously healthy, immunocompetent 17-year-old male patient, who developed acute glomerulonephritis during the course of Parvovirus B19 infection and this acute glomerulonephritis did not resolve spontaneously. His renal biopsy showed mild mesangial proliferation and focal segmental sclerosis. Parvovirus B19 DNA was detected in renal tissue by polymerase chain reaction.

Parvovirus B19-induced multisystem disease simulating systemic vasculitis in a young child

Parvovirus B19 mostly presents as a transient viral illness or as pure red cell aplasia. However, this virus can sometimes cause an illness that may pose diagnostic difficulties. We describe one such patient who had clinical features simulating a vasculitic disorder secondary to parvovirus B19 infection.

Nephrotic syndrome associated with human parvovirus B19 infection

A previously healthy 8-year-old Japanese boy developed nephrotic syndrome during the course of erythema infectiosum due to human parvovirus B19 (PVB19) infection. A renal biopsy showed mesangiocapillary proliferative glomerulonephritis with immune complex deposits associated with PVB19 virus. His renal involvement improved spontaneously.