Intravenous immunoglobulin treatment of four patients with juvenile polyarticular arthritis associated with persistent parvovirus B19 infection and antiphospholipid antibodies

Abstract

Parvovirus B19 infection has been associated with a wide spectrum of diseases. Besides acute infection resulting in anaemia and erythema infectiosum (fifth disease), a rash illness of childhood, hydrops fetalis in pregnant women and acute symmetrical polyarthropathy in adults have been reported as clinical manifestations. Depending on the haematological status of the host, B19 infection can be associated with haematopoietic disorders such as antiplastic crisis, thrombocytopenia and pancytopenia. Hepatitis, myocarditis, myositis, neurological disease and vasculitis can occur occasionally [1]. The relation of the infection to acute arthritis-arthralgias in children is well known. Some of the affected children develop chronic arthritis that is indistinguishable from juvenile idiopathic arthritis [2][3][4][5]. In these patients parvovirus B19 could ANA = anti-nuclear antibodies; anti-PL IgG = antiphospholipid antibodies; β 2 GPI = β 2 -glycoprotein I; CK = creatine kinase; CRP = C-reactive protein; ENA = extractable nuclear antigens; ESR = erythrocyte sedimentation rate; IVIG = intravenous immunoglobulin; KINDL = Health-related Quality of Life Questionnaire for Children; MTX = methotrexate; NSAID = non-steroidal anti-inflammatory drugs; TCHA = triamcinolone hexaacetonid; VP1 = viral protein 1; VP2 = viral protein 2. Online ISSN 1478-6362). This is an Open Access article: verbatim copying and redistribution of this article are permitted in all media for any purpose, provided this notice is preserved along with the article's original URL. AbstractChildren with rheumatic oligoarthritis and polyarthritis frequently establish persistent parvovirus B19 infections that may be associated with the production of antiphospholipid antibodies (anti-PL IgG). In this study we analysed the influence of high-dose intravenous immunoglobulin (IVIG) therapy on virus load, on the level of anti-PL IgG and its potential capacity to improve the patients' clinical status. Four juvenile patients with long-lasting polyarticular rheumatic diseases and persistent parvovirus B19 infection, associated in three cases with the presence of antibodies against β 2 -glycoprotein I (anti-β 2 GPI IgG), were treated with two cycles of IVIG on five successive days (0.4 g/kg per day). Clinical parameters including scores of disease activity, virus load and anti-PL IgG levels were determined before, during and after treatment. Two patients showed a complete remission that has lasted 15 months. During that period they showed neither clinical nor laboratory signs of inflammation. Viral DNA was not detectable in serum, and a decrease in anti-β 2 GPI IgG was observed. As assessed by the Childhood Health Assessment Questionnaire and the Health-related Quality of Life Questionnaire for Children, both patients were no longer restricted in their activities of daily living and no impact on the health-related quality of life was observed. In one patient the therapy failed: there was no improvement of symptoms and no decrease in virus load or inflammatory parameters. ...

Human Parvoviruses

“…There are sporadic, unique reports of immunological abnormalities of uncertain clinical significance: histocompatibility antigen overrepresentation and low complement levels (480), low levels of proinflammatory cytokines and chemokines (481), and anti-NS1 antibodies (482). As B19V does not circulate in arthropathy patients, and the significance of detection of viral DNA in joint fluid or tissue is unclear, there is no obvious justification for immunoglobulin therapy, and the benefit of its occasional use (483,484) is uncertain due to polypharmacy and/or natural resolution of the inflammatory process.…”

Parvoviruso B19 Infekcijos Klinikiniai Simptomai, Diagnostika Ir Gydymas

“…Ryški aplastinė anemija gydoma alogenine kaulų čiulpų transplantacija, imunosupresine terapija, gali būti taikoma IVIG infuzija [13,14]. Esant imunosupresijai, su virusu asocijuotoms artropatijoms ir pacientams, turintiems gretutinių hematologinių sutrikimų, paprastai skiriamas IVIG 3-5 dienas [15]. Pacientams po transplantacijos rekomenduojamas imunosupresijos mažinimas [16].…”

Intravenous immunoglobulin: prospects in patients with autoimmune rheumatic diseases

“…Lehmann и соавт. [32] сообщили о 4 случаях успешного лечения ВВИГ больных ЮХА с сопутствующей вирусной инфекцией парвовирусом B19 и антифосфолипидными антителами. ВВИГ назначали в дозе 0,4 г/кг в течение 5 дней.…”