Chronic pure red cell aplasia caused by parvovirus B19 in AIDS: Use of intravenous immunoglobulin?A report of eight patients

Abstract

The optimal management of chronic pure red cell aplasia caused by parvovirus B19 (B19-PRCA) in patients with AIDS is unclear. Our purpose was to determine the effects of intravenous immunoglobulin (IVIg) in the treatment of B19-PRCA in patients with AIDS. The patients were eight adults with AIDS admitted during the period 1993-1997. A diagnosis of B19-PRCA was made if all the following criteria were met: 1. Bone marrow biopsy finding of pure red cell aplasia; 2. Detection of parvovirus B19 DNA in serum; and 3. No alternative explanation for PRCA. Initial (induction) therapy was with IVIg 1 g/kg daily for 1-2 days. Relapses were treated with IVIg 1 g/kg for 2 days. Maintenance therapy with IVIg 0.4-1.0 g/kg q 4 weeks was given to those patients who developed a second or subsequent relapse. The patients were followed for a mean of 27 months (range 8-38 months). All patients responded to initial therapy with IVIg. Six patients with CD4 counts < 80 cells/mm3 relapsed. The response was short lived in two patients with a CD4 count < 80 cells/mm3 who were given a single infusion of IVIg 1 g/kg as initial therapy. Four patients were given regular maintenance IVIg therapy following a second or subsequent relapse and remain in remission. Two patients whose CD4 counts were > 300 cells/mm3 remain in continuous unmaintained remission from B19-PRCA for over 8 and 11 months, respectively, following induction therapy with IVIg. AIDS patients with B19-PRCA respond well to therapy with IVIg 2 g/kg given over 2 days. Most patients with CD4 counts of < or = 80 cells/mm3 suffer relapse within six months necessitating retreatment with IVIg; maintenance therapy with IVIg 0.4 g/kg q 4 weeks is effective in preventing relapse of B19-PRCA, and may be cost effective. Routine maintenance therapy is probably not indicated in patients with CD4 counts over 300 cells/mm3. Prospective studies are needed to confirm these findings.

Use of intravenous immunoglobulin in human disease: A review of evidence by members of the Primary Immunodeficiency Committee of the American Academy of Allergy, Asthma and Immunology

“…Several case reports describe the successful use of IGIV in the treatment of anemia caused by chronic erythrovirus (formerly parvovirus) B-19 infection. [280][281][282] IGIV therapy was also shown to clear viremia and improve symptoms and cytokine dysregulation in the erythrovirus B-19-associated chronic fatigue syndrome. 283 Because this viral infection is prevalent in the general population, IGIV contains a significant antierythrovirus titer and was considered the only specific treatment for infection.…”

Pure red cell aplasia caused by parvovirus B19 in two patients without chronic hemolysis

“…Acquired immunodeficiency syndrome that notoriously reduces T-cell function, use of alemtuzumab that acts against CD4-and-8 positive T cells, or systemic lupus erythematosus, a representative collagen disease, even in the inactive stage, accompanies parvoviral PRCA [16][17][18]. In addition, PVB19 DNA was detected at high frequencies in recipients of renal transplantation [19] and patients with acute lymphoblastic leukemia during chemotherapy [20], both of whose Hb level was lower.…”

“…Even prophylactic administration of Ig after rituximab was previously suggested [13]. However, eradication of the virus occasionally fails, resulting in persistent infection in immunodeficient patients [7,8,16]. Several adverse reactions of Ig therapy, i.e., aseptic meningitis, hemolytic anemia, renal dysfunction [21], and transmission of PVB19 [22], are also notable.…”

Therapeutic Use of Immunoglobulins

“…The IVIG dose needed to eradicate parvovirus in not established but is large (1-2 g/kg) and should be repeated until the virus is eradicated as indicated by serum polymerase chain reaction analysis [62,63].…”