#00066475

A 72-year-old male, with past medical history of bilateral lung transplant for idiopathic pulmonary fibrosis, complicated by CMV viremia. He is on tacrolimus, mycophenolate, predinislone, and azithromycin. He has no history of acute rejection of the lung transplant. He is HIV negative, with negative fungal and acid fast bacilli cultures. He developed chronic pancytopenia with acute worsening anemia and leukopenia. He has diabetes mellitus type 2 on metformin, chronic kidney diseases type 3 with increased creatinine, hypertension and non-obstructive coronary artery disease. He complains of fatigue, and feels cold. He reports having fever and sore throat which resolved. He has worsening appetite and his diet is not the best. He has lost 5 lbs of non-intentional weight loss. He denies night swears, nausea, vomiting, and abdominal pain. His familial history is not contributory. He is a former smoker and he doesn’t drink alcohol. He worked in construction and was exposed to chemicals and radiations. Physical exam shows no lymphadenopathy, no hepatosplenomegally, with normal cardiovascular, lung, neurological, and extremities exams. Skin exam shows worm dry skin with no rash, petechiae or ecchymosis noted.  He has normal direct, indirect, and total bilirubins. His lactic dehydrogenase was slightly increased: 213 U/L. His complete blood count (CBC) at that time showed: WBC: 1.2 10*3/uL, Hemoglobin: 6.9 g/dL, Hematocrit: 24.7%, MCV: 85.2 fL, Platelets 131 10*3/uL, and absolute neutrophilic count (ANC): 900. The case was transferred for hematology and a bone marrow biopsy was performed.

The marrow biopsy showed; (A) normocellular marrow (30-40%) with unremarkable granulocytic and megakaryocytic hematopoiesis, decreased erythroid precursors with scattered erythroid precursors cells showing intranuclear inclusions suspicious for viral infection (insert). The marrow smear highlights the affected erythroid precursors with viral inclusions (B & C) Immunohistochemical (IHC) stains for parvovirus B19 highlights the infected cells (D). CMV, EBV, Adenovirus, and HSV immunostains were negative.

A diagnosis of parvovirus B19 infection is stablished. He was given IVIG infusions in the setting of immunocompromised status. He requires recurrent transfusions for the anemia and G-CSF for the low ANC. His symptoms started to improve despite having ongoing fatigue.

Parvovirus B19 infection is a small DNA virus with tropism for erythroid precursors in the bone marrow, where it suppresses erythropoiesis and can cause transient aplastic crisis, particularly in patients with underlying hemolytic or chronic anemia. In immunocompromised individuals, including patients with HIV infection, serologic testing may be negative because they are unable to produce adequate IgG antibodies, making molecular detection methods important for diagnosis. Chronic infection is characterized by persistent anemia, erythroid hyperplasia, and prominent viral inclusions within basophilic and polychromatic erythroblasts. In fetuses, infection may involve the placenta and fetal tissues, leading to hydrops fetalis or fetal death. Clinically, Parvovirus B19 is also the cause of erythema infectiosum (Fifth disease) and can be associated with arthropathy, although the significance of detectable B19 DNA in rheumatic disease remains uncertain. Viral DNA has also been identified in the bone marrow of a small percentage of healthy individuals, and related viruses such as Erythrovirus V9 may produce similar pathologic findings.