Prevalence of human parvovirus B19 and TT virus in a group of young Haemophiliacs in South Africa

A well recognized hazard of transfusion with blood or blood products is the acquisition of a viral infection. Parvovirus B19 and transfusion transmitted virus (TTV) are two of several non-enveloped viruses that may on rare occasions be present in coagulation factor concentrates. The prevalence of these viruses in the South African Haemophilia population has not previously been studied. Thirty-nine Haemophiliac children were investigated for evidence of parvovirus and TTV infection. 26 boys with Haemophilia A had been treated with cryoprecipitate or intermediate purity factor VIII, and 13 boys with Haemophilia B had received prothrombin complex concentrates. All the plasma products were prepared from South African donors and were virally inactivated by heat or solvent/detergent since 1992. A control group of 32 children who had not been transfused were also studied. IgG antibodies to B19 were present in 29 of the 39 patients (74%), 18/26 (69%) with Haemophilia A and 12 of the 13 (85%) with Haemophilia B. None of the patients was IgM antibody positive but two children were PCR positive for B19 DNA. Of the control children, 47% had IgG antibodies to B19, but none were IgM antibody or B19 DNA positive. TTV viral DNA was found in 10.2% of patients and in 9% of the control group. The results indicate that our locally produced plasma products are not a significant source of TTV transmitted infection but may contribute to infection by B19 parvovirus.     

Successful high-titer immunoglobulin therapy for persistent parvovirus B19 infection in a lymphoma patient treated with rituximab-combined chemotherapy

A 40-year-old female diagnosed with follicular lymphoma was treated with rituximab-combined chemotherapy. Although she achieved complete remission, she developed progressive anemia and reticulocytopenia. Bone marrow examination revealed features of pure red cell aplasia and hemophagocytosis. In addition, the appearance of large pronormoblasts suggested that she was infected with parvovirus B19. Excess viral DNA in her bone marrow confirmed that her illness was caused by persistent parvovirus B19 infection. Serum immunoglobulin levels decreased beyond the lower normal limit, which indicated that her humoral immunity was impaired after rituximab-combined chemotherapy. Although she had been infected with parvovirus B19, she was re-infected and failed to control the viral expansion. High-titer immunoglobulin against parvovirus B19 was intravenously administrated and resulted in remarkable reticulocytosis and improvement of anemia. High-titer immunoglobulin, which contained a sufficient amount of neutralizing antibodies against parvovirus B19, likely inactivated most viruses in vivo. We successfully eradicated the virus after 2 courses of high-dose therapy at 0.5 g/kg/day every week followed by 8 courses of maintenance therapy at 0.1 g/kg/day every other week. It is important to consider that parvovirus B19 infection is a possible cause of progressive anemia in B-cell lymphoma patients treated with rituximab-combined chemotherapy. We propose that the use of high-titer immunoglobulin against parvovirus B19 may enable such immunocompromised patients to eradicate the virus before sufficient immune system reconstruction.     

Persistence of B19 parvovirus in synovial membranes of patients with rheumatoid arthritis

Summary Recent clinical observations support the hypothesis that persistent parvovirus B19 is a triggering factor of rheumatoid arthritis (RA) in certain genetically predisposed individuals. If this hypothesis is correct, a number of RA patients may exhibit parvovirus B19 DNA in their synovial membranes. We tested the synovial tissue and peripheral blood leukocytes of 20 patients with RA, 24 patients with other arthritides or osteoarthritis (non-RA), and 34 healthy blood donors for the presence of parvovirus B19 DNA using specific DNA amplification by polymerase chain reaction (PCR). Using this technique, parvovirus B19 DNA was demonstrated in the synovial biopsies of 75% of patients with RA but in those of only 16.7% of patients with non-RA. In autologous peripheral blood mononuclear cells the percentage of PCR-positive patients was about 15% in both RA and non-RA groups and did not differ from that in healthy controls. When the PCR data were correlated with the presence of anti-parvovirus B19 IgG antibodies in serum and synovia all patients with parvovirus B19 DNA in peripheral blood alone or in both peripheral blood and synovial membrane were seropositive. In contrast, about 40% of patients with parvovirus B19 DNA restricted to the synovial membrane were seronegative. These data indicate a highly disease-related persistence of parvovirus B19 in the rheumatoid synovium.     

Prevalence of parvovirus B19 DNA in bone marrow of patients with haematological disorders.

Patients with haematological disorders (n = 100) were examined for prevalence of parvovirus B19 DNA in the bone marrow and serum, irrespective of B19-related symptoms. B19 DNA was studied using 2 nested PCRs and the serum samples were further analysed with B19-specific IgG, IgM and avidity as well as seroreactivity against linear and conformational epitopes of the B19 VP2 antigen. The latter assays specify whether the IgG antibody response represents acute or past B19 infection. B19 DNA was detected in 4 of the 100 bone marrow samples, whereas all the serum samples were B19 DNA negative. None of the 4 B19 DNA positive patients had symptoms typical of B19 infection and serology showed past infection. Furthermore, 2 were still B19 DNA positive in bone marrow more than 1 y after the first sample indicating virus persistence. The seroprevalence for B19 IgG was 59% and 2 patients were B19 IgM positive. Thus, presence of B19 DNA in bone marrow from patients with haematological disorders is not a general finding in seropositive patients. B19 DNA can persist in bone marrow, but in our material this finding showed no clear correlation with symptomatic B19 infection.     

Parvovirus B19 quiescence during the course of human immunodeficiency virus infection in persons with hemophilia

To detect and characterize parvovirus B19 infection during the course of progressive immune deficiency from human immunodeficiency virus (HIV), ten subjects enrolled in the Multicenter Hemophilia Cohort Study were followed for 6.4 to 15 years from HIV seroconversion through extreme immune deficiency. Four to five sera or plasma samples from each subject, collected at predetermined CD4⁺ lymphocyte levels, were tested for immunoglobulin G (IgG) and M (IgM) B19 antibodies and DNA. All 42 samples were positive for B19 IgG antibodies, and three were weakly positive for IgM antibodies. Only one sample, collected coincident with HIV seroconversion, was unequivocally positive for B19 DNA. No persistent hematologic adverse effects of B19 infection were observed. Thus, although B19 IgG antibodies are highly prevalent among HIV-infected persons with hemophilia or related disorders, B19 viremia and its hematologic consequences were not detected, even with severe depletion of CD4⁺ lymphocytes. If primary B19 infection occurs after immune deficiency, however, the consequences may be more adverse. Am. J. Hematol. 56:248–251, 1997. © 1997 Wiley-Liss, Inc.     

Agranulocytosis associated with parvovirus B19 infection in otherwise healthy patients

In the course of 6 years, 23 otherwise healthy patients with acute febrile illness and leukopenia were diagnosed as having acute parvovirus B19 infection. Five of these patients had agranulocytosis associated with acute parvovirus B19 infection and one had chronic agranulocytosis due to persistent parvovirus B19 infection. The diagnosis was made after positive anti-parvovirus B19 IgM antibodies were found in all of the patients and viral DNA was detected by PCR in four patients. Neutropenia and agranulocytosis appear to be much more frequently associated with parvovirus B19 infection than previously reported.     

Acute parvovirus B19 infection in pregnant women—An analysis of serial samples by serological and semi-quantitative PCR techniques

Summary The serological and virological course of parvovirus B19 infection was followed in 14 women who suffered symptomatic or subclinical acute infection during pregnancy. Serial serum samples from the patients were tested for IgG and IgM antibodies and the levels of parvovirus B19 DNA were monitored using a semi-quantitative PCR assay. In addition, the outcome of the pregnancies was documented by clinical information and by testing cord blood for parvovirus B19 specific antibodies as well as for parvovirus B19 DNA by PCR. Levels of IgG antibodies rose steadily within 2 months of infection and in some cases began to decline at the end of pregnancy. IgM antibodies were usually detected for at least 2 months and persisted for as long as 9 months in one case. Viral DNA was detectable for at least 8 weeks following infection and semi-quantitative analysis revealed a gradual reduction in virus load during the viraemic phase of infection. There were no apparent differences in the course of antibody development and duration of viraemia in symptomatic versus subclinical infections.     

The relationship between arthritis and human parvovirus B19 infection

In order to evaluate the role of human parvovirus B19 in the etiopathogenesis of autoimmune diseases such as rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE), synovial fluid and blood specimens were collected at 1-month intervals from 20 patients with early synovitis (ES) and 31 with RA. Blood specimens were also collected from 25 patients with SLE, 25 with osteoarthritis (OA) as the diseased control group, and 50 healthy blood donors (HBD) as the healthy control group. Detection of B19 IgM and B19 IgG were performed by enzyme-linked immunosorbent assay from serum specimens, and B19 DNA was detected by polymerase chain reaction from synovial fluid samples. B19 IgM, B19 IgG, and B19 DNA were found in the three patients of the ES group. Subsequently, two of them were diagnosed with RA and one with SLE. B19 DNA was also detected in the synovial fluid of eight patients in the RA group. Of them, all were positive for B19 IgG and half were positive for B19 IgM. B19 IgM was not detected in either of the control groups. To define the role of B19 in the etiopathogenesis and prognosis of undiagnosed arthritis and other chronic inflammatory diseases such as RA and SLE, we need broader serial and prospective studies based on clinical and laboratory collaboration. In conjunction with case reports, these studies would also serve to detect other possible factors in the etiopathogenesis of chronic inflammatory diseases.     

A case of pure red cell aplasia and systemic lupus erythematosus caused by human parvovirus B19 infection

Human parvovirus B19 (B19) rarely induces pure red cell aplasia (PRCA) in healthy hosts. Meanwhile B19 infection is often clinically similar to systemic lupus erythematosus (SLE), and several cases have been reported wherein B19 actually stimulated SLE exacerbation in an immunocompetent subject. An 82-year-old healthy woman was diagnosed to have complicated with B19 infection and PRCA. Four weeks later, she had high fever, polyarthritis, and oral ulcers, additionally diagnosed with SLE, and subsequently, 15 mg of prednisone was started. This is the first case wherein B19 infection caused both PRCA and SLE in a healthy patient as far as our investigations are concerned.     

Parvovirus B19 transmitted by bone marrow

We describe a case of symptomatic parvovirus B19 infection transmitted by bone marrow (BM). The infection caused prolonged anaemia, thrombocytopenia, arthralgia and erythema infectiosum in a 16-year-old girl with acute myeloid leukaemia receiving a BM transplant (BMT). The BM donor was a 19-year-old asymptomatic brother who had parvovirus B19 viraemia at the time of BM harvest. Sequencing of the VP2 gene from the patient and the donor showed a perfect match of DNA sequences, confirming the mode of transmission. Parvovirus B19 represents a potential complicating factor in patients undergoing BMT, but screening by polymerase chain reaction (PCR) of donor BM may reduce the risk of infection.     

Serological and virological markers of human parvovirus B19 infection in patients with haemophilia

Clotting factor concentrates prepared from human plasma are a potential route of parvovirus B19 (B19) infection in patients with coagulation disorders. However, it is not clear whether B19 transmits and persistently infects patients with haemophilia, especially those with HIV infection. We examined serological and virological markers of B19 in samples from 40 patients with haemophilia who had been receiving several brands of clotting factor concentrates. All of them were anti-B19 IgG seropositive and anti-B19 IgM seronegative. The levels of anti-B19 IgG were significantly higher in haemophiliacs than in healthy donors, whereas there was no difference between the level of anti-B19 IgG in haemophiliacs with HIV infection and those without HIV infection. Moreover, there was no difference between the level of anti-B19 IgG in haemophiliacs receiving recombinant factor VIII and that in those receiving plasma-derived clotting factors. Although by using polymerase chain reaction (PCR) B19 DNA was detected at very low levels (< 40 DNA copies mL⁻¹, in 3 out of 40 haemophiliacs, persistent B19 infection was negligible.     

Epidemiology of high-level parvovirus B19 viraemia among Dutch blood donors, 2003-2009

Background and Objectives Plasma derivatives and blood components with low levels of parvovirus B19 (B19) seem not infectious, but recently infected, highly viraemic donors may transmit B19. We studied the incidence of high‐level B19 viraemia (B19 DNA > 10⁶ IU/ml) in 6·5 million Dutch blood donations. Materials and Methods Between 2003 and 2009, all Dutch blood and plasma donations were screened for the presence of B19 DNA, via pools of 480. Reactive pools were resolved and demographic parameters were obtained for all donors with B19 viraemia > 10⁶ IU/ml. In a subset, IgG and IgM antibodies to B19 were determined. Results Four hundred and eleven donations (1/15815) were identified with B19 DNA levels above 10⁶ IU/ml, predominantly (83%) occurring in donors aged 18–47 years. Each year infection rates were elevated between December and July, with April accounting for 16% of infections. The years 2004 and 2009 were epidemic, with up to 1/4880 highly viraemic donations in May 2004. In a subset of 67 viraemic donations, 47/67 (70%) tested negative for IgG and IgM antibodies to B19; 16/67 (24%) showed isolated IgM and 4/67 (6%) contained IgG and IgM antibodies. The seasonal pattern of asymptomatic B19 infection in blood donors followed the notification rate of clinical cases. Geographically, B19 infection was randomly spread over the Netherlands. Conclusions In epidemic seasons, blood donations with high levels of parvovirus, without concurrent antibodies, are common. They may infect immunocompromised and parvovirus‐naïve recipients. The feasibility of preventive measures should be studied.     

Antibodies to parvovirus B19 non-structural protein are associated with chronic but not acute arthritis following B19 infection

OBJECTIVE: To determine the incidence and significance of antibodies to the parvovirus B19 non-structural (NS1) protein in B19-infected persons during acute infection and convalescence. METHODS: The B19 NS1 protein was expressed in SF9 cells using the baculovirus expression system and was used to prepare immunofluorescence slides. These were used in a fluorescent antibody test to determine anti-B19 NS1 IgG in a well-characterized cohort of 53 persons at the time of acute B19 infection and again after a follow-up period of 26-85 months. Results were examined for statistical significance by the use of Fisher's exact test. RESULTS: NS1 antibodies were detected in five of 32 persons with acute B19 infection (four with arthritis) and 10 of 53 persons with past B19 infection (six with chronic arthritis and two with chronic arthritis and chronic fatigue syndrome). Regarding the correlation of NS1 antibodies and arthritis, at the time of acute infection four of 24 persons with arthritis had NS1 antibodies detected compared with one of eight persons with any other symptoms (P: = 1). During convalescence, eight of 20 persons with chronic arthritis had NS1 antibodies compared with two of 33 with symptoms of any other category (all except one were asymptomatic) (P: = 0.007). All 10 patients with NS1 antibodies during convalescence had arthritis during acute infection, which persisted in eight persons until the time of follow-up. CONCLUSION: Antibodies to parvovirus B19 NS1 protein are associated with chronic but not with acute arthritis after B19 infection.     

Parvovirus B19 infection-induced anemia and leukocytopenia after myomectomy

A 38-year woman was hospitalized because of myoma uteri. She underwent myomectomy on September 30, 1997 with 2,000 ml blood loss. No blood transfusion was required, but she received a plasma protein product. On the 14th postoperative day, a complete blood count revealed anemia (Hb 9.3 g/dl) and leukocytopenia (1,600/ul). But it did not reveal anemia before the operation. Bone marrow smears showed erythroblastopenia with giant proerythroblasts. Anti-parvovirus B19 IgM antibody were positive in the serum and parvovirus B19 DNA was detected in the bone marrow cells by polymerase chain reaction. From the results, the patient was diagnosed as the anemia and leukocytopenia secondary to parvovirus B19 infection. Parvovirus B19 was not detected in the samples of the plasma protein product received on the myomectomy. The reticulocyte gradually decreased to 1/1000 on the 20th postoperative day. The anemia and leukocytopenia gradually improved. This case shows that parvovirus B19 infection could cause hematological disorders in the normal person under acute blood loss. This report warns that a careful observation is necessary for the patients who have received operations with acute blood loss.     

Pure red cell aplasia induced by B19 parvovirus during allogeneic bone marrow transplantation

We report a patient who had abrupt onset of pure red cell aplasia (PRCA) induced by B19 parvovirus during allogeneic bone marrow transplantation (BMT). A 14-year-old girl with APL in complete remission was admitted in February 1988, for the purpose of BMT. She was received marrow from HLA identical sister on March 17, 1988 (day 0). She received 120 mg/kg cyclophosphamide and 12 Gy total body irradiation for conditioning of BMT. For graft-versus-host disease (GVHD) prophylaxis she was given cyclosporine and short term methotrexate. She did not develop acute GVHD after BMT, but on the day 28 a bone-marrow aspirate revealed findings of PRCA. During this course the number of white blood cell and platelet favorably recovered. B 19 parvovirus DNA was detected in the serum of the day 30 and day 42. Antihuman B 19 parvovirus (HPV) antibody titers were increased: the values of anti-HPV IgM were suddenly elevated and those of anti-HPV IgG were elevated. Serum on the day 42 inhibited erythroid progenitors (CFU-E, BFU-E) but not inhibited myeloid progenitors (CFU-C). A reticulocyte count recovered on the day 50. As the patient was HPV-IgG negative prior to BMT and the donor was HPV-IgG seronegative, the source of infection may be platelet transfusion (day 7 through 14).     

Acute parvovirus B19 infection mimicking juvenile myelomonocytic leukemia

An 11-month-old patient with parvovirus infection mimicking juvenile myelomonocytic leukemia (JMML) is presented. The patient's history, presenting physical and laboratory features, was suggestive of JMML and consisted of fever, hepatosplenomegaly, lymphadenopathy, desquamation of the skin, anemia, leukocytosis with monocytosis and trilineage dysplastic findings of the peripheral blood and bone marrow. However, positive IgM titers for parvovirus B19 followed by seroconversion, negative cytogenetics and the benign follow-up of the patient suggested acute parvovirus infection as an etiologic factor for development of dysplastic features in the patient, and thus is recommended for consideration in the differential diagnosis of MDS. Although parvovirus B19 infection mimicking MDS has previously been shown in two patients with spherocytosis and one with subclinical immune deficiency; to our knowledge, the present report is the first describing the association of acute parvovirus B19 infection with dysplastic features mimicking myelodysplasia (MDS) in a child without a demonstrable underlying hematolymphoid disorder.     

Prevalence of antibodies to human parvovirus B19 nonstructural protein in persons with various clinical outcomes following B19 infection.

Persistent infections with human parvovirus B19 (B19) associated with debilitating chronic disease have been described, although evidence linking B19 to these more unusual clinical outcomes has been inconclusive. Recent reports have suggested that the development of antibodies to the B19 nonstructural protein (NS1) following B19 infection might be linked to development of severe arthropathy and chronic infection. To confirm these findings, the C-terminal region of the NS1 protein was expressed for use in Western blot assays for detection of anti-NS1 IgG antibodies in human serum. Among 91 persons tested, 0 of 20 not previously infected with B19, 9(36%) of 25 with past B19 infection, and 5 (12.5%) of 40 with recent B19 infection, had detectable anti-NS1 antibodies. Of 6 persons with chronic B19 infection, 2 had detectable antibodies to NS1. The presence of anti-NS1 antibodies did not appear to correlate with unusual clinical outcomes or chronic B19 infection.     

Parvovirus B19 infection and idiopathic thrombocytopenic purpura*

 The potential association of human parvovirus B19 infection with idiopathic thrombocytopenic purpura (ITP) was studied. All 60 adult patients presenting with ITP at the University Hospital Rotterdam – Dijkzigt during a 12-year period (41 with acute ITP, 19 with chronic ITP) were included. Patient files were retrospectively analyzed. Stored serum samples were tested for parvovirus B19-specific IgG and IgM antibodies, and for parvovirus B19 DNA. In only one patient (1.7%) was evidence of recent B19 infection found. Parvovirus B19 is not a frequent cause of adult ITP and should be tested for only when there are other indications of possible parvovirus B19 involvement. Received: 9 October 1995 / Accepted: 14 November 1995     

Parvovirus B19 diagnosis in pregnant women — quantification of IgG antibody levels (IU/ml) with reference to the international parvovirus B19 standard serum

Summary On the basis of the results of a collaborative study the Expert Committee on Biological Standardisation of the World Health Organisation has issued an international standard (IS) serum for parvovirus B19 IgG antibody (NIBSC 93/724). In this study this IS was used to calibrate an in-house standard serum for reporting the results of parvovirus B19 IgG testing in IU/ml. The IgG titre distribution in 939 pregnant women was determined. These samples were sent to the laboratory for determining the immune status to parvovirus B19 following contact with parvovirus B19 infected individuals or for detecting acute infection in patients with symptoms suggestive of parvovirus B19 infection.     

人微小病毒B19感染所致肝损害19例临床分析

目的探讨B19病毒感染所致肝损害的临床表现、实验室检查特点及治疗与转归。方法对人微小病毒B19感染患者19例的临床资料进行回顾性分析。结果在人微小病毒B19感染的19例患者,主要症状有乏力(12例)、黄疸(10例)、脾肿大(10例),伴有发热(10例)、皮疹(6例)及肌肉关节疼痛(6例),有6例伴有如下疾病或并发症:如妊娠(1例)、急性肝功能衰竭(2例)、精神分裂症(1例)、急性骨髓停滞(1例)和肺炎(1例)。以血清天门冬氨酸氨基转移梅(AST)升高为主,黄疸大多数表现为轻到中度,容易出现凝血酶原活动度(PTA)下降,但胆碱脂酶(CHE)下降不明显。经积极对症支持治疗,肝功能等各项指标正常后治愈出院。人微小病毒B19可致肝功能受损,导致急性肝炎或急性重型肝炎。结论对临床上非甲～戊型肝炎病人,应注意检查血清抗B19病毒IgM。该病毒感染是一个急性或亚急性过程,呈良性经过,有自愈倾向。