Letter to the Editor
Parvovirus B19 chronic monoarthritis in a patient with common variable immunodeficiency
Monoartritis crónica por parovirus B19 en un paciente con inmunodeficiencia común variable
Lucía Ruiz Gutiérrez
, Fernando Albarrán, Henry Moruno, Eduardo Cuende
Corresponding author
Servicio de Enfermedades del Sistema Inmune/Reumatología, Hospital Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
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A 48-year-old man was referred to the hospital because of right wrist monoarthritis lasting six months. Physical examination showed swelling of the right wrist not associated with erythema, warmth or skin lesions. Laboratory analyses showed a white blood cell count of 8300/mm<span class="elsevierStyleSup">3</span> (91% granulocytes, 4% lymphocytes), an erythrocyte sedimentation rate (ESR) of 67<span class="elsevierStyleHsp" style=""></span>mm/h and a C-reactive protein (CRP) of 9.4<span class="elsevierStyleHsp" style=""></span>mg/l. Serum electrophoresis demonstrated hypogammaglobulinemia: 0.06<span class="elsevierStyleHsp" style=""></span>g/dl (IgG<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>8.6<span class="elsevierStyleHsp" style=""></span>mg/dl, IgA<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>7.8<span class="elsevierStyleHsp" style=""></span>mg/dl, IgM<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>29.8<span class="elsevierStyleHsp" style=""></span>mg/dl). Rheumatoid factor and antinuclear antibodies were negative. Low values of C3 and C4 were found (64<span class="elsevierStyleHsp" style=""></span>mg/l and 1.5<span class="elsevierStyleHsp" style=""></span>mg/l, respectively). Serologic tests for <span class="elsevierStyleItalic">Borrelia burgdorferi</span>, hepatitis B and C, rubeolla and mumps virus, enterovirus, cytomegalovirus, Epstein Barr virus, human immunodeficiency virus and parvovirus B19 were negative. A bone gammagraphy showed marked fixation of the tracer in the right carpus, suggestive of arthritis. A magnetic resonance displayed diffuse synovitis of the right distal radio-cubital joint, with no signs of necrosis or osteomyelitis. A synovial biopsy was performed; hystopathological studies showed chronic nonspecific inflammatory changes and polymerase chain reaction (PCR) detected the presence of parvoviral B19 DNA in synovial tissue. PCR of parvovirus B19 DNA in blood was positive.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A diagnosis of parvoviral B19 monoarthritis in the setting of CVID was made, and prompt treatment with intravenous immunoglobulin (0.4<span class="elsevierStyleHsp" style=""></span>g/kg every 4 weeks) was administered with complete resolution of articular symptoms after the second infusion. Because of hypogammaglobulinemia, treatment with intravenous immunoglobulin was continued indefinitely. Human parvovirus B19 infection is detected in 3.3% of patients examined for acute reactive arthritis.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Joint symptoms usually resolve within two weeks; however, 0–17% of patients has chronic arthritis,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> generally a symmetric polyarthritis that can resemble rheumatoid arthritis. Chronic monoarthritis is much less frequent. To our knowledge, five cases of parvovirus B19 chronic monoarthritis have been described: three children<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> and two adults.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Diagnosis of B19 infection in immunocompetent individuals is made by detection of B19 specific antibodies in blood. Caution should be made when interpreting serology for parvovirus B19 in immunodeficient patients and pregnant women because of their decreased capacity to mount an antibody response. In these patients, serology should be complemented by PCR analyses of B19 DNA.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In our patient, serologic tests for parvovirus B19 were negative and diagnosis was made by PCR of blood serum and synovial tissue. Even though the presence of parvovirus B19 DNA in synovial tissue does not allow a definite diagnosis, the absence of other causes and the rapid response to intravenous immunoglobulin, led us to assume the viral aetiology of the arthritis.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">CVID is a primary immune deficiency characterized by reduced levels of immunoglobulins of all classes despite normal numbers of circulating B cells. The deficiency in IgG production may lead to recurrent infections with encapsulated organisms, such as <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> and <span class="elsevierStyleItalic">Heamophilus influenzae</span>, causing otitis, sinusitis, bronchitis and bronchiectasis. Septic arthritis with usual bacterial pathogens such as <span class="elsevierStyleItalic">Staphylococcus aureus</span>, <span class="elsevierStyleItalic">S. pneumoniae</span> and <span class="elsevierStyleItalic">H. influenzae</span> and unusual bacteria such as mycoplasma and ureaplasma species, have been described in these patients. Viral arthritis are uncommon; the main causes are adenovirus type I and echovirus 11 and a few cases related to parvovirus B19 have been reported.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> An aseptic no erosive polyarticular arthritis that resembles rheumatoid arthritis is seen in 10–30% of hypogammaglobulinemic patients. These types of arthritis respond well to immunoglobulin replacement treatment.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8–10</span></a> To our knowledge, only one other case of persistent parvovirus infection leading to a diagnosis of CVID has been reported; it is the case of a 6-year-old boy who presented with a 1-month history of fever and polyarticular arthritis in whom laboratory investigation showed hypogammaglobulinemia. Intravenous immunoglobulin was started 2 weeks into the illness, resulting in prompt recovery.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">This case highlights the importance of considering the diagnosis of parvovirus B19 infection not only in cases of polyarthritis but also in any case of unexplained chronic monoarthritis and the special situation of immunodeficient individuals, in whom serologic tests can be negative.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ruiz Gutiérrez L, Albarrán F, Moruno H, Cuende E. Monoartritis crónica por parovirus B19 en un paciente con inmunodeficiencia común variable. 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| 2022 January | 37 | 34 | 71 |
| 2021 December | 40 | 36 | 76 |
| 2021 November | 45 | 39 | 84 |
| 2021 October | 42 | 48 | 90 |
| 2021 September | 29 | 36 | 65 |
| 2021 August | 27 | 36 | 63 |
| 2021 July | 16 | 28 | 44 |
| 2021 June | 28 | 34 | 62 |
| 2021 May | 31 | 32 | 63 |
| 2021 April | 63 | 96 | 159 |
| 2021 March | 37 | 21 | 58 |
| 2021 February | 16 | 22 | 38 |
| 2021 January | 23 | 27 | 50 |
| 2020 December | 27 | 24 | 51 |
| 2020 November | 25 | 24 | 49 |
| 2020 October | 14 | 13 | 27 |
| 2020 September | 32 | 30 | 62 |
| 2020 August | 19 | 16 | 35 |
| 2020 July | 23 | 11 | 34 |
| 2020 June | 28 | 20 | 48 |
| 2020 May | 21 | 6 | 27 |
| 2020 April | 24 | 21 | 45 |
| 2020 March | 19 | 7 | 26 |
| 2020 February | 1 | 0 | 1 |
| 2018 December | 2 | 0 | 2 |
| 2018 May | 2 | 0 | 2 |
| 2018 April | 31 | 11 | 42 |
| 2018 March | 31 | 7 | 38 |
| 2018 February | 21 | 7 | 28 |
| 2018 January | 18 | 6 | 24 |
| 2017 December | 24 | 4 | 28 |
| 2017 November | 22 | 9 | 31 |
| 2017 October | 33 | 7 | 40 |
| 2017 September | 21 | 8 | 29 |
| 2017 August | 30 | 9 | 39 |
| 2017 July | 18 | 17 | 35 |
| 2017 June | 42 | 8 | 50 |
| 2017 May | 39 | 13 | 52 |
| 2017 April | 44 | 7 | 51 |
| 2017 March | 40 | 8 | 48 |
| 2017 February | 19 | 15 | 34 |
| 2017 January | 17 | 12 | 29 |
| 2016 December | 52 | 14 | 66 |
| 2016 November | 27 | 16 | 43 |
| 2016 October | 42 | 15 | 57 |
| 2016 September | 42 | 7 | 49 |
| 2016 August | 36 | 8 | 44 |
| 2016 July | 30 | 7 | 37 |
| 2016 June | 1 | 0 | 1 |
| 2016 May | 1 | 0 | 1 |
| 2016 February | 1 | 0 | 1 |
| 2015 December | 2 | 0 | 2 |
| 2015 September | 1 | 0 | 1 |
| 2015 August | 1 | 0 | 1 |
| 2015 July | 14 | 8 | 22 |
| 2015 June | 28 | 9 | 37 |
| 2015 May | 58 | 12 | 70 |
| 2015 April | 69 | 15 | 84 |
| 2015 March | 26 | 9 | 35 |
| 2015 February | 50 | 14 | 64 |
| 2015 January | 28 | 18 | 46 |
Show all
