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
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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 "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Usefulness of routine hepatitis C virus, hepatitis B virus, and parvovirus B19 serology in the diagnosis of recent-onset inflammatory arthritides" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A. 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| 2024 Marzo | 92 | 24 | 116 |
| 2024 Febrero | 81 | 21 | 102 |
| 2024 Enero | 45 | 24 | 69 |
| 2023 Diciembre | 36 | 27 | 63 |
| 2023 Noviembre | 53 | 29 | 82 |
| 2023 Octubre | 61 | 35 | 96 |
| 2023 Septiembre | 116 | 52 | 168 |
| 2023 Agosto | 61 | 42 | 103 |
| 2023 Julio | 54 | 29 | 83 |
| 2023 Junio | 62 | 29 | 91 |
| 2023 Mayo | 55 | 21 | 76 |
| 2023 Abril | 40 | 10 | 50 |
| 2023 Marzo | 82 | 34 | 116 |
| 2023 Febrero | 67 | 40 | 107 |
| 2023 Enero | 58 | 35 | 93 |
| 2022 Diciembre | 66 | 47 | 113 |
| 2022 Noviembre | 74 | 40 | 114 |
| 2022 Octubre | 70 | 36 | 106 |
| 2022 Septiembre | 57 | 40 | 97 |
| 2022 Agosto | 59 | 54 | 113 |
| 2022 Julio | 71 | 46 | 117 |
| 2022 Junio | 50 | 52 | 102 |
| 2022 Mayo | 61 | 48 | 109 |
| 2022 Abril | 131 | 53 | 184 |
| 2022 Marzo | 93 | 53 | 146 |
| 2022 Febrero | 70 | 42 | 112 |
| 2022 Enero | 59 | 42 | 101 |
| 2021 Diciembre | 80 | 47 | 127 |
| 2021 Noviembre | 66 | 44 | 110 |
| 2021 Octubre | 89 | 55 | 144 |
| 2021 Septiembre | 54 | 52 | 106 |
| 2021 Agosto | 51 | 42 | 93 |
| 2021 Julio | 42 | 35 | 77 |
| 2021 Junio | 53 | 33 | 86 |
| 2021 Mayo | 64 | 42 | 106 |
| 2021 Abril | 129 | 101 | 230 |
| 2021 Marzo | 114 | 54 | 168 |
| 2021 Febrero | 79 | 34 | 113 |
| 2021 Enero | 75 | 36 | 111 |
| 2020 Diciembre | 68 | 24 | 92 |
| 2020 Noviembre | 81 | 25 | 106 |
| 2020 Octubre | 92 | 16 | 108 |
| 2020 Septiembre | 81 | 40 | 121 |
| 2020 Agosto | 40 | 27 | 67 |
| 2020 Julio | 44 | 29 | 73 |
| 2020 Junio | 56 | 26 | 82 |
| 2020 Mayo | 68 | 38 | 106 |
| 2020 Abril | 85 | 32 | 117 |
| 2020 Marzo | 103 | 40 | 143 |
| 2020 Febrero | 58 | 35 | 93 |
| 2020 Enero | 55 | 20 | 75 |
| 2019 Diciembre | 53 | 40 | 93 |
| 2019 Noviembre | 50 | 23 | 73 |
| 2019 Octubre | 84 | 27 | 111 |
| 2019 Septiembre | 109 | 51 | 160 |
| 2019 Agosto | 91 | 29 | 120 |
| 2019 Julio | 79 | 25 | 104 |
| 2019 Junio | 62 | 32 | 94 |
| 2019 Mayo | 88 | 68 | 156 |
| 2019 Abril | 74 | 35 | 109 |
| 2019 Marzo | 53 | 40 | 93 |
| 2019 Febrero | 40 | 38 | 78 |
| 2019 Enero | 45 | 33 | 78 |
| 2018 Diciembre | 82 | 71 | 153 |
| 2018 Noviembre | 71 | 12 | 83 |
| 2018 Octubre | 63 | 16 | 79 |
| 2018 Septiembre | 40 | 6 | 46 |
| 2018 Agosto | 22 | 6 | 28 |
| 2018 Julio | 12 | 8 | 20 |
| 2018 Mayo | 3 | 0 | 3 |
| 2018 Abril | 39 | 7 | 46 |
| 2018 Marzo | 44 | 4 | 48 |
| 2018 Febrero | 27 | 5 | 32 |
| 2018 Enero | 17 | 3 | 20 |
| 2017 Diciembre | 25 | 10 | 35 |
| 2017 Noviembre | 29 | 10 | 39 |
| 2017 Octubre | 32 | 15 | 47 |
| 2017 Septiembre | 25 | 10 | 35 |
| 2017 Agosto | 42 | 3 | 45 |
| 2017 Julio | 34 | 13 | 47 |
| 2017 Junio | 47 | 6 | 53 |
| 2017 Mayo | 35 | 10 | 45 |
| 2017 Abril | 38 | 5 | 43 |
| 2017 Marzo | 25 | 33 | 58 |
| 2017 Febrero | 38 | 3 | 41 |
| 2017 Enero | 30 | 2 | 32 |
| 2016 Diciembre | 60 | 11 | 71 |
| 2016 Noviembre | 45 | 13 | 58 |
| 2016 Octubre | 77 | 15 | 92 |
| 2016 Septiembre | 49 | 9 | 58 |
| 2016 Agosto | 27 | 7 | 34 |
| 2016 Julio | 21 | 3 | 24 |
| 2016 Abril | 1 | 0 | 1 |
| 2016 Marzo | 1 | 0 | 1 |
| 2015 Diciembre | 2 | 0 | 2 |
| 2015 Octubre | 1 | 0 | 1 |
| 2015 Septiembre | 1 | 0 | 1 |
| 2015 Julio | 47 | 10 | 57 |
| 2015 Junio | 62 | 7 | 69 |
| 2015 Mayo | 68 | 17 | 85 |
| 2015 Abril | 58 | 25 | 83 |
| 2015 Marzo | 48 | 17 | 65 |
| 2015 Febrero | 118 | 49 | 167 |
| 2015 Enero | 137 | 71 | 208 |
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