Korean J Transplant.  2020 Sep;34(3):199-203. 10.4285/kjt.2020.34.3.199.

Recurrent parvovirus B19 infection-associated pure red cell aplasia in a kidney transplant patient

Affiliations
  • 1Department of Surgery, Seoul National University Hospital, Seoul, Korea
  • 2Department of Laboratory Medicine, Seoul National University Hospital, Seoul, Korea
  • 3Transplantation Research Institute, Seoul National University College of Medicine, Seoul, Korea
  • 4Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
  • 5Transplantation Center, Seoul National University Hospital, Seoul, Korea

Abstract

Posttransplant anemia is a common complication after kidney transplantation. Parvovirus B19 (PVB19) infection can induce pure red cell aplasia (PRCA) in immunosuppressed transplant patients. We herein report a case of recurrent PVB19-associated PRCA in a kidney transplant patient. A 49-year-old woman presented with anemia and normal renal function 1 year after a deceased-donor kidney transplantation for immunoglobulin A nephropathy-related end-stage renal disease. She received desensitization therapy, and 2 years later, she underwent transplantation with thymoglobulin induction. Despite repeated red cell transfusion and erythropoietin therapy, her anemia aggravated progressively. Bone marrow biopsy revealed normocytic normochromic PRCA. Real-time polymerase chain reaction detected a high plasma load of PVB19. Administration of intravenous immunoglobulin (IVIG) at 2 g/kg with adjuvant reduction of tacrolimus and discontinuation of myfortic acid effectively treated the anemia. However, the PVB19 load remained high, and PRCA recurred 7 months after the initial IVIG treatment. Tacrolimus was switched to cyclosporine in the second IVIG treatment, which successfully improved PRCA and reduced the PVB19 load. Our case suggested that PVB19-associated PRCA should be suspected when persistent anemia is observed in kidney transplant patients with heavy immunosuppression and that PVB19-associated PRCA can recur in the presence of persistent PVB19 viremia.

Keyword

Intravenous immunoglobulin; Kidney transplantation; Parvovirus B19 infection; Pure red cell aplasia

Figure

  • Fig. 1 Bone marrow aspiration findings. Wright-Giemsa staining (×1,000) images of bone marrow aspiration smears showing (A) giant pronormoblasts with nuclear viral inclusion bodies (nucleoli-like, eosinophilic inclusion body, arrow) and (B) giant pronormoblasts with “dog ear” cytoplasmic projections (arrow).

  • Fig. 2 Changes in blood cell count after kidney transplantation. The patient’s hemoglobin level dropped from 14.0 g/dL at 12 months posttransplant to 7.4 g/dL at 14 months posttransplant. Despite erythropoietin treatment, anemia progressed to 4.2 g/dL, requiring two cycles of red blood cell transfusion. Intravenous immunoglobulin (IVIG) treatment initiated at 17 months posttransplant normalized her hemoglobin level at 19 months posttransplant. However, anemia recurred at 24 months posttransplant, and the second IVIG treatment initiated at 25 months Posttransplant successfully improved her anemia. IS, immunosuppressants; MMF, mycophenolate mofetil.


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