Isolated Anemia in a 69-Year-Old Man with HIV-1: Features of Pure Red Cell Aplasia Mediated by Chronic Parvovirus-B19 Infection

Abstract

Patient: Male, 64-year-old Final Diagnosis: Parvovirus-B19 pure red cell aplasia Symptoms: Lethargy • syncope • weight loss Medication: — Clinical Procedure: Blood transfusion • bone marrow biopsy • immunoglobulin therapy Specialty: Hematology • Infectious Diseases • General and Internal Medicine Objective: Rare disease Background: Pure red cell aplasia (PRCA) is an uncommon syndrome characterized by ineffective erythropoiesis and severe anemia. Among immunodeficient patients, including those with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), persistent parvovirus-B19 can cause PRCA. We report a rare case of an Australian man with parvovirus-B19 mediated PRCA secondary to a new diagnosis of HIV-1/AIDS. The case highlights the importance of early treatment initiation with anti-retroviral drugs and pooled immunoglobulins to enable marrow recovery and long-term disease remission. Case Report: A 64-year-old man residing in rural Indonesia presented with severe anemia. Apart from 8 kg of unintentional weight loss, he denied any occult bleeding, diatheses, or constitutional symptoms. His bloodwork revealed a normocytic, normochromic anemia (Hb 81 g/L) with profound reticulocytopenia (9.5×10 9 /L). Parvovirus-B19 serology and polymerase chain reaction testing confirmed active viremia. Lymphopenia and an undetectable CD4 T-lymphocyte count (<1%) were also noted; HIV-1 was subsequently diagnosed. Bone marrow sampling later confirmed features consistent with parvovirus-B19-driven PRCA secondary to HIV-1/AIDS. The patient received 1 g/kg intravenous immunoglobulin for two days and initiated anti-retroviral HIV therapy. Rapid reticulocytosis with slow incrementation of his hemoglobin were observed over one month. At three years following his diagnosis, he remains in remission. Conclusions: Severe, isolated anemia in immunodeficient patients, particularly those with HIV-1/AIDS, should prompt consideration of parvovirus-B19-mediated PRCA. Depletion of CD4-T-lymphocyte populations enables the establishment of parvovirus-B19 reservoirs within erythroid progenitors, thereby hampering physiological erythropoiesis. Long-term remission can be achieved with the rapid institution of intravenous immunoglobulin and anti-retroviral HIV therapies.

Evaluation of human herpesvirus‐8 viremia and antibody positivity in patients with HIV infection with human herpesvirus‐8‐related diseases

“…Remission was achieved through the administration of a gamma globulin preparation in some cases, while in others, anti-PVB19-IgG antibodies increased after ART, followed by remission. [9][10][11] However, the role of humoral immunity against HHV-8 in HHV-8-related diseases has not been fully characterized. [12][13][14] The anti-HHV-8 antibody titer was higher in the mothers of HHV-8negative children than in the mothers of HHV-8-positive children.…”

“…Cases of PVB19‐related pure red cell aplasia in HIV‐infected patients have been reported. Remission was achieved through the administration of a gamma globulin preparation in some cases, while in others, anti‐PVB19‐IgG antibodies increased after ART, followed by remission 9–11 . However, the role of humoral immunity against HHV‐8 in HHV‐8‐related diseases has not been fully characterized 12–14 .…”

Clinical Presentation of Parvovirus B19 Infection in Adults Living with HIV/AIDS: A Case Series

“…The relationship between anemia and B19V infection is well known [ 4 , 10 , 11 , 12 ]. B19V DNA was detected by dot blot hybridization in sera from 5 of 30 (17%) PLWHA with Ht <24% and 4 of 13 (31%) patients with Ht < 20% in a study published in 1997, suggesting that B19V was a substantial contributor to severe anemia in HIV infection in the pre-high-potency ART era [ 13 ].…”

“…Pure red cell aplasia (PRCA) has been described in patients living with HIV/AIDS (PLWHA), affecting up to 4.5% of patients [ 2 , 3 ]. Therefore, some authors recommend the prompt consideration of B19V-mediated PRCA for PLWHA with severe isolated anemia [ 4 ]. Patients with persistent or recurrent viremia have absent or low levels of specific antibodies.…”