Parvovirus B19-induced multisystemic vasculitis and acute endocapillary proliferative glomerulonephritis in a child

Abstract

A 10-year-old girl was admitted with fever, cough, maculopapular rash, hemoptysis, dark-colored urine, edema, multiple lymphadenopathies, and hepatosplenomegaly. She developed acute glomerulonephritis during the course of these complex clinical features. Laboratory data showed hematuria, proteinuria, and hypocomplementemia. Serological tests showed positive human parvovirus B19 (HPVB19)-specific immunoglobin M (IgM) and HPVB19 DNA was detected in the patient's serum using polymerase chain reaction (PCR). Renal biopsy revealed acute endocapillary proliferative glomerulonephritis (AEPGN) with coarse granular C3 depositions in a "starry sky pattern," which is more peculiar to poststreptococcal glomerulonephritis. Electron microscopy showed subendothelial and small hump-shaped subepithelial electron-dense deposits in glomerular capillary walls. There was no evidence of either any mycobacterial, staphylococcal, or streptococcal infection, and the diagnosis of Goodpasture syndrome and connective tissue disorders was excluded during clinical and laboratory investigations. A diagnosis of HPVB19-induced pleuropneumonitis and glomerulonephritis was made. Through a literature search there was no documented pediatric case of AEPGN induced by HPVB19, and this case represents, to our knowledge, the first time that a direct relationship between parvovirus infection and AEPGN has been demonstrated in a child.

Clinical impact & pathogenic mechanisms of human parvovirus B19

“…Low-level expression of viral gene has been observed in some cells with persistent infection and B19V capsid mRNA or proteins have been detected in the bone marrow, synovial, heart, liver, colon, lymphoid, thyroid and testicular tissues with different disease outcomes116117. Since vascular endothelial cells line all blood vessels which in turn supply blood to all organs through arteries, arterioles and capillaries and possess receptor for B19V, these get infected by B19V and induce multi-systemic vasculitis, necrotizing vasculitis, endothelialitis and micro-angiopathy118119120 and cause various diseases. To study the mechanisms underlying B19V infection and B19V DNA replication, many types of cell culture systems, including permissive and semipermissive erythroid lineage cells besides non-permissive cells, such as human embryonic kidney 293 or the endothelial cells of the myocardium, have been utilized121.…”

Starry sky pattern of fetal liver sonogram as first sign of twin–twin transfusion syndrome

“…Abdominal sonography showed ascites and a diffuse starry sky appearance of the liver8. A starry sky pattern on liver sonography has also been identified in patients with leukemia7, toxic shock syndrome9, Burkitt's lymphoma10 and fasting liver11, and it has been mentioned in connection with other diseases as well, such as meningitis12 and parvovirus infection13, although acute hepatitis7 is the most common cause.…”

Vasculitis related to viral and other microbial agents

“…The target cells include endothelium as well as erythroid progenitors, megakaryocytes, fetal myocytes, and placental trophoblasts. Acute PVB19 infection has been associated with clinical features suggestive of vasculitis; these include intestinal ischemia [121,122], papularpurpuric "glove and stocking" syndrome [123], mononeuritis multiplex [124], IC glomerulonephritis [125], and dermal infarction [122]. The known endothelial tropism of PVB19 has prompted numerous investigations for the potential role of the virus in the pathogenesis of other established vasculitic disorders (Table 1).…”