Parvovirus B19-Induced Autoimmune Response

Patient Presentation
K.B., a 26 year-old healthy young woman, went on a service trip to Peru in early May. K.B. felt fine upon her return to America for the first two weeks. Starting May 30th, K.B. slept for a minimum of 16 hours everyday.  This sleeping pattern continued for approximately two more weeks. On June 1st, K.B. experienced severe pain in her left wrist. On June 7th, an x-ray of the wrist was taken. The x-ray looked fine, and the pt was given an NSAID and a splint and sent home. From June 9th –August 19th, the pt experienced the following symptoms: syncope upon waking in the morning, migratory polyarthritis, erythema and swelling of joints, pleuritis, photosensitivity, severe mouth sores, and chronic fatigue. Throughout the three months, K.B. was seen by her PCP, infectious disease doctors, and rheumatologists.

Differential List
A myriad of doctors throughout the summer assessed K.B. and checked her blood for the following possible diagnoses: systemic lupus erythematosus, autoimmune hepatitis, rheumatory arthritis, HIV, adenovirus, enterovirus, dengue fever, lupus-mimic induced by parvovirus, and viral-induced autoimmune response, with EBV, parvovirus, and Lyme disease as potential culprits.

Diagnosis
The current belief is that K.B. is suffering from an autoimmune response induced by parvovirus that she contracted while in Peru.

Treatment
June- July: CBC: WNL except for  PLTs 427 (slightly elevated) and Lymphocytes 21% (slightly low) BMP: WNL; ESR: 27 (elevated); Rheumatoid Factor: (-); ANA 1:640 (indicating an autoimmune response); anti-double stranded DNA for lupus (-); smooth muscle antibody (+) (usually means immune system is attacking liver/gallbladder); U/A normal. Serum parvovirus: IgG 3.9 (elevated) IgM 7 (elevated). Usually once the IgGs appear, the migratory joint pain is no longer caused by the parvovirus, but an autoimmune disease.

August 19th pt went to ID specialist: ANA: 1:340-1:1280 (elevated). C4 complement: 9 (low - a common finding in lupus flares). Cardiolipin IgA Autoantibodies (lupus anticoagulant testing): 15 (high - showing some autoimmune attack on the heart). Viral load test of parvovirus B19 (human strain): 5,000 DNA copies per ml (high).

Pt put on meloxicam 15 mg daily, an NSAID commonly prescribed for arthritis.

Outcome/Prognosis
The ID doctor plans to recheck the ANA and viral load of parvovirus B19 in 6 months. If the viral load remains high, the doctor will consider this a chronic parvovirus, typically seen in HIV/AIDS and other immunosuppressed patients. Parvovirus can enter the bone marrow and cause aplastic anemia, for which, IVIG will be the next treatment to help the body fight infection. Despite the chronic joint inflammation K.B. has been suffering over the past three months, her MD doesn’t think there will be permanent damage.  The literature shows that parvovirus tends to linger in young women and that this severe parvovirus infection is extremely rare. The doctor told K.B. that for now, she must be prepared for a “slow, painful misery.”