Central nervous system vasculitis secondary to parvovirus B19 infection in a pediatric renal transplant patient

Abstract

Central nervous system (CNS) vasculitis secondary to chronic parvovirus B19 (B19) infection presenting with recurrent neurological findings is a very rare disorder during childhood. Here we report a 12-year-old boy with a renal transplant who had chronic B19 infection with skin eruptions and recurrent episodes of encephalopathy with focal neurological deficits. B19 DNA was detected in blood, bone marrow, and skin biopsy specimens. Repeat cranial magnetic resonance (MR) imaging during each episode of encephalopathy showed variable focal findings, and MR angiography revealed vasculitic changes with narrowing of the cerebral arteries. We hypothesized that the CNS vasculitis might be associated with the chronic B19 infection. At the time of his fourth presentation with the same clinical findings, we administered intravenous immunoglobulin (IVIG) (1 g/kg per day, 2 consecutive days), which we continued for 6 months, at monthly intervals. IVIG therapy resulted in remission and has been effective not only for the clearance of B19, but also for the improvement of clinical and radiological findings of CNS vasculitis. We suggest that chronic B19 infection should be considered in immunocompromised patients with suspected CNS vasculitis. IVIG should be considered as a part of the treatment.

Neurologic Manifestations Associated with Parvovirus B19 Infection

“…Rash was reported more often among immunocompetent patients than it was among patients with altered immunity (OR, 11.5; 95% CI, 2.4-53.8). Rash preceded the onset of other disease manifestations in 13 (45%) of 29 cases, usually by a few days; however, in a case involving a renal transplant recipient, rash preceded the onset of other disease manifestations by 3 months [58]. Rash followed the onset of other disease manifestations in 6 (21%) of 29 cases by 3-20 days.…”

Parvovirus B19 Infection after Transplantation: A Review of 98 Cases

“…Ninety-one cases of PVB19 infection were reported. Including the 7 cases we described here, the data from a total of 98 patients are summarized in [7, 10, 11, 16, 18, 24, 26, 30-32, 36, 39, 44, 45, 47, 48, 58, 68], skin rash occurred in 13.3% [12,24,28,31,36,39], and arthralgia occurred in 6.0% of patients [18,22,35,38,68]. PVB19-associated anemia was accompanied by organ-invasive manifestations in 11% of patients, including myocarditis (probable cases in 2% of patients; possible cases in 2% of patients) [17,22,28,43,57], pneumonitis (definite cases in 1%; probable cases in 1%; possible cases in 1%) [22,31,68], hepatitis (probable cases in 2%; possible cases in 2%) [28,58,63,66], and collapsing glomerulopathy (probable cases in 1%) [26].…”

Parvovirus B19 and the Kidney

“…Furthermore, neutropenia, thrombocytopenia, or pancytopenia may occasionally accompany the anemia, further broadening the differential diagnosis (77). Other clinical complications that have been linked with B19 infection in renal transplant recipi-ents include liver dysfunction (84), fibrosing cholestatic hepatitis (85), encephalitis (86), and cerebral vasculitis (87). However, causality has been difficult to infer in many cases.…”