Discordant Outcomes in a Case of Parvovirus B19 Transmission Into Both Dichorionic Twins

Abstract

Maternal infection with parvovirus B19 during pregnancy can cause aplastic anemia in the fetus and may lead to nonimmune fetal hydrops and fetal demise. Twin pregnancies complicated by infection due to parvovirus B19 are very rare clinical events. We present a dichorionic, diamniotic, dizygotic twin pregnancy after in vitro fertilization with parvovirus B19 infection and viral transmission to both twins, but different outcomes. At 19 weeks gestation, hydrops fetalis was diagnosed for male twin A, female twin B did not show any abnormalities. At 22 weeks gestation an acute parvovirus B19 infection was detected and twin A was diagnosed with intrauterine fetal death (IUFD) by ultrasound at 23 weeks gestation. Viral DNA was detected in maternal blood as well as in placenta and liver tissue of this twin. Twin B was born at 35 weeks gestation asymptomatically and no signs of hydrops or other congenital anomalies but viral DNA was detected by PCR in serum. At the age of 2 years, both IgG titres against B19 and parvovirus DNA amplification copies were still positive in plasma of the surviving twin, but no clinical signs were detectable. It is remarkable that both twins were infected with parvovirus B19 early in pregnancy but showed a discordant clinical outcome. Our case report describes the rare occurrence of an intrauterine fetal death (IUFD) of one twin and the asymptomatic infection of the other in a twin pregnancy.

Infections at the maternal–fetal interface: an overview of pathogenesis and defence

“…The rare but classic sequela of parvovirus B19 is non-immune fetal hydrops caused by transient, severe anaemia with loss of both erythrocytes and nucleated erythroid precursors 129 . Dichorionic twin discordance in infection and in clinical sequelae has been reported 131 , 132 , suggesting that the placental and fetal responses are important for limiting clinical disease, but the immune mechanisms by which this occurs are unclear.…”

Human Parvoviruses

“…In one prospective study of third-trimester fetal death, 7.5% of placentas contained B19V DNA (510). The variability in transmission from mother to fetus is illustrated by instances of infection and death of only a single twin (511,512).…”

Seroepidemiology of parvovirus B19 in the Frankfurt am Main area, Germany: evaluation of risk factors

“…In most cases, transmission of this virus occurs via respiratory droplets, by blood transfusion or by through the use of blood-derived drugs [2,3]. In addition to horizontal infection, PV B19 may also be vertically transmitted in utero during pregnancy [4].…”