December 21, 2024

48-year-old man takes immunosuppressant medications develops low-grade fever and rash

By Med-Challenger · 1 minute read

A 48-year-old man takes immunosuppressant medications following a kidney transplant for polycystic kidney disease. He develops low-grade fever followed by a facial rash that eventually spreads to his extremities in a lacy, reticular pattern. His joints ache, and he is fatigued.

He is found to be quite anemic, with a hemoglobin level of 7 g/dL. The anemia is normocytic and normochromic. Platelet and white blood cell counts are normal. His iron level is normal and his reticulocyte count is 1.5%. The result from the Coombs test is negative. Findings on bone marrow biopsy show giant proerythroblasts.

Which of the following viruses is associated with this clinical picture?

hepatitis A virus (HAV)
cytomegalovirus (CMV)
parvovirus B19V
Epstein–Barr (EBV) virus

The correct answer is:

parvovirus B19V

Educational Objective:

Consider parvovirus infection as an etiology of red cell dysplasia in an immunocompromised patient.

Key Point:

In immunocompromised patients, severe anemia secondary to bone marrow red cell dysplasia can be caused by parvovirus B19V.

Explanation:

Parvovirus B19V is known chiefly as the cause of fifth disease, or erythema infectiosum, characterized by a "slapped-cheek" appearance in children and also by arthralgias in adults. In most individuals, infection with parvovirus B19V causes a transient, asymptomatic reticulocytopenia.

Infection with parvovirus B19V is also associated with pure red cell aplasia, with characteristic giant proerythroblasts in the bone marrow, particularly in patients with long-term immunosuppression. In immunosuppressed patients, intravenous immunoglobulin can be used to treat red cell aplasia due to parvovirus infection.

EBV, CMV, and HAV infections can cause a very brief red cell aplasia often not clinically recognized.

References:

Frickhofen N, Chen ZJ, Young NS, Cohen BJ, Heimpel H, Abkowitz JL. Parvovirus B19 as a cause of acquired chronic pure red cell aplasia*. Br J Haematol.* 1994;87:818-824.

Rogo LD, Mokhtari-Azad T, Kabir MH, et al. Human parvovirus B19 a review. Acta Virol. 2014;58:199-213.

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