Its All in the Rash: The Association of Parvovirus B‐19 and Type 1 Cryoglobulinemia

1Marshfield Clinic, Marshfield, WI
2Marshfield Clinic, Marshfield, WI

Meeting: Hospital Medicine 2013, May 16-19, National Harbor, Md.

Abstract number: 419

Case Presentation:

A 62‐year‐old man with a history of exposure to his grandchild diagnosed with erythema infectiosum presented with a 1‐week history of fever, polyarthralgias, and myalgias. Evaluation revealed a platelet count of 68,000 and Hgb 15.7. CT scan showed splenomegaly and intra‐abdominal lymphadenopathy. He presented 2 days later and was hospitalized for generalized urticaria, pruritus and lightheadedness. Platelet count at that time was 17,000, Hgb 7.2, and reticulocyte index 0.68. Laboratory studies were negative for Lyme and Ehrlichia serology. Peripheral blood film examination showed thrombocytopenia, areas of red cell agglutination, very rare schistocytes, and LDH > 900. The aPTT, PT and fibrinogen levels were normal. DAT was positive for IgG only and serologic tests (ELISA and IF assays) for PB‐19 were positive for IgM and IgG antibodies. Viral studies (HBV, HCV, HIV, and CMV) and autoimmune panel (ANA, ANCA, and anti‐GBM) were normal. On hospital day 5 he developed acute renal failure requiring hemodialysis. Renal biopsy showed thrombotic microangiopathy and cortical necrosis and ADAMTS13 was 57%. Flow cytometry showed findings consistent with low‐grade lymphoproliferative disorder (LPD). On hospital day 7 he developed a diffuse painful maculopapular rash sparing his back, intertriginous areas and oral mucosa with areas of necrosis. Cryoglobulins (CGs) were positive (CG 3% and IF showed type I cryoglobulinemia) and skin biopsy revealed findings consistent with cryoglobulinemia. He was started on high‐dose IV steroids and plasmapheresis. Bone marrow biopsy was significant for 20% small lymphocytes and <5% plasma cells consistent with LPD. He was treated with 4 doses of rituximab with resolution of symptoms clinically.

Discussion:

We report an unusual case of a patient with type I CG and parvovirus infection with overlapping clinical and laboratory features. Immune‐mediated autoimmune hemolytic anemia, thrombocytopenia and CG have been reported to occur in both these conditions. In patients with parvovirus B19 (PB‐19) infection, autoimmune antibodies may be induced due to the presence of proinflammatory cytokines or shared antigenic epitopes between viral and host cells. Type I CG is typically found in patients with lymphoproliferative disorders or multiple myeloma, whereas type II is typically associated with viral infections. Patients with type 1 cryoglobulinemia, as found in our patient, may rarely develop renal disease as a result of thrombotic disease. We speculate that immune stimulation and lymphoproliferation due to the PB‐19 may have accounted for the pathogenic CG response

Conclusions:

Though parvovirus is commonly associated with type II/III CG, one needs to recognize the rare but plausible association of PB‐19 with type I CG. Also understand the appropriate treatment of type I CG associated with parvovirus B19 and low‐grade lymphoproliferative disorder

To cite this abstract:

Epperla N, Yale S. Its All in the Rash: The Association of Parvovirus B‐19 and Type 1 Cryoglobulinemia. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 419. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/its-all-in-the-rash-the-association-of-parvovirus-b19-and-type-1-cryoglobulinemia/. Accessed September 16, 2019.

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