Parvovirus B19 in solid organ transplant recipients

Metagenomic Next-Generation Sequencing Reveals the Profile of Viral Infections in Kidney Transplant Recipients During the COVID-19 Pandemic

Background

To study the clinical application of metagenomic next-generation sequencing (mNGS) in the detection of viral infections in kidney transplant recipients (KTRs) during the COVID-19 pandemic.

Methods

Using mNGS technology, 50 human fluid samples of KTRs were detected, including 20 bronchoalveolar lavage fluid (BALF) samples, 21 urine samples and 9 blood samples. The detected nucleic acid sequences were compared and analyzed with the existing viral nucleic acid sequences in the database, and the virus infection spectrum of KTRs was drawn.

Results

The viral nucleic acids of 15 types of viruses were detected in 96.00% (48/50) of the samples, of which 11 types of viruses were in BALF (95.00%, 19/20), and the dominant viruses were torque teno virus (TTV) (65.00%; 13/20), cytomegalovirus (CMV) (45.00%; 9/20) and human alphaherpesvirus 1 (25.00%; 5/20). 12 viruses (95.24%, 20/21) were detected in the urine, and the dominant viruses were TTV (52.38%; 11/21), JC polyomavirus (52.38%; 11/21), BK polyomavirus (42.86%; 9/21), CMV (33.33%; 7/21) and human betaherpesvirus 6B (28.57%; 6/21). 7 viruses were detected in the blood (100.00%, 9/9), and the dominant virus was TTV (100.00%; 9/9). Four rare viruses were detected in BALF and urine, including WU polyomavirus, primate bocaparvovirus 1, simian virus 12, and volepox virus. Further analysis showed that TTV infection with high reads indicated a higher risk of acute rejection (P < 0.05).

Conclusions

mNGS detection reveals the rich virus spectrum of infected KTRs, and improves the detection rate of rare viruses. TTV may be a new biomarker for predicting rejection.

Parvovirus B19-associated graft failure after allogeneic hematopoietic stem cell transplantation

Background

Parvovirus B19 (PVB19) infection has been implicated in allograft failure or dysfunction in solid organ transplantation (SOT) and allogeneic hematopoietic stem cell transplantation (allo‐HSCT), but the literature is limited.

Case

Two pediatric patients were diagnosed with PVB19 infection around the time of allo‐HSCT graft failure. Both cases were secondary graft failure and required second allo‐HSCT.

Conclusion

There are many risk factors and potential confounders in determining the exact etiology of graft failure after allo‐HSCT. These two cases highlight the importance of including PVB19 in the diagnostic evaluation for graft failure. PVB19 infection may be an important risk factor for allo‐HSCT graft failure.

Tale of two viruses: parvovirus B19 and HIV

We present a HIV-infected patient who developed severe anaemia due to chronic parvovirus B19 infection and subsequently had an unplanned pregnancy. This is in the context of poor adherence to antiretroviral therapy and significant immunosuppression; there was a delay in diagnosis of chronic parvovirus infection due to attribution of anaemia to HIV. She received immunoglobulin therapy and effective antiretroviral therapy, with reduction in parvovirus load and improvement in anaemia. She was counselled regarding the need for monitoring in pregnancy due to risk of intrauterine infection. We review the literature of management of chronic parvovirus infection in the immunosuppressed and the consequences of intrauterine infection.

Transfusion-Dependent Anemia in a Simultaneous Pancreas and Kidney Transplant Recipient

A case of transfusion-dependent anemia in a simultaneous pancreas and kidney (SPK) transplant recipient that masqueraded as gastrointestinal bleeding (GIB) is described. The anemia was attributed to bleeding from the donor duodenal cuff based on balloon enteroscopy findings. The patient underwent multiple contrast-enhanced computed tomography scans and multiple endoscopies with confounding features until, eventually, the diagnosis was established. We discuss the diagnostic difficulties and the therapeutic dilemma, along with the pitfalls in ascertaining the final diagnosis.

Human parvovirus B19 infection induced pure red cell aplasia in liver transplant recipients

AIM

Th aim of this study was to explore the diagnosis and treatment of pure red cell aplasia (PRCA) induced by human parvovirus B19 (HPV B19) infection in liver transplant recipients.

METHODS

We described and analysed the clinical manifestation, diagnosis, treatment and prognosis of the 13 liver transplant recipients confirmed to have PRCA induced by HPV B19.

RESULTS

In the past 3 years, 13 liver transplant recipients out of a cohort of 570 recipients were confirmed to have PRCA induced by HPV B19. Some experienced fever (eight patients) but all of the patients had a gradual decline of haemoglobin levels within 2 months posttransplantation. The diagnosis was confirmed by several tests including bone marrow aspiration and polymerase chain reaction (PCR) assays. All recipients achieved remission using symptomatic treatment that included intravenous immunoglobulins (IVIG), immunosuppressive regimen switch and blood transfusion.

CONCLUSION

Pure red cell aplasia induced by HPV B19 infection is a disease with a favourable prognosis after symptomatic and supportive treatment. (i) Pure red cell aplasia anaemia is a prominent clinical sign of HPV B19 infection in liver transplant recipients. (ii) PCR technology combined with bone marrow aspiration and other laboratory examinations will meet the requirement for the diagnosis and suggests that the differential diagnosis includes PRCA and graft versus host disease (GVHD). (iii) IVIG is recommended as the first regimen for the treatment of PRCA induced by HPV B19 infection in liver transplant recipients. IVIG can be repeated if the patient has a relapse. (iv) A switch of the baseline immunosuppressive regimen may achieve a favourable curative effect.

Emerging and Rare Viral Infections in Transplantation

Immunocompromised patients such as those undergoing solid organ or hematopoietic stem cell transplantation are at substantial risk for infection with numerous pathogens. Infections with cytomegalovirus (CMV), herpes simplex virus (HSV), Epstein–Barr virus (EBV), and human herpesvirus-6 (HHV-6) are well-described complications of transplantation. As viruses previously believed to be quiescent through widespread vaccination (e.g., measles and mumps) reemerge and molecular diagnostic techniques are refined, rare and emerging viral infections are increasingly diagnosed in transplant recipients. This chapter will review the clinical manifestations, diagnosis, and potential antiviral therapies for these viruses in the transplant population.

Effects of Parvovirus B19 Infection in Renal Transplant Recipients: A Retrospective Review of Three Cases

Parvovirus B19 (PVB19) is a DNA virus which causes clinically relevant infection in renal transplant recipients (RTR) leading to significant morbidity. Manifestations include erythropoietin resistant anemia, proteinuria, and glomerulosclerosis in the allograft. Severe infection may require administration of intravenous immunoglobulin, reduction in immunosuppression and transfusions. The major challenge in managing and preventing the infection in RTR involves the act of balancing the decreased level of immunosuppression and the risk of rejection. The objective of this article is to understand the importance of PVB19 infection and its outcome in RTR. We reviewed the medical records of three RTR with confirmed PVB19 infection and recorded patient information including demographics, clinical and laboratory data, management, and outcome. The average time of occurrence of PVB19 infection as transplant was 8.6 weeks and they presented with symptomatic anemia. Elevated creatinine values were noted in two of them. Following treatment, anemia improved and creatinine values returned to baseline. One of them developed an early relapse and had to be treated once again similarly. We emphasize the importance of maintaining a high index of suspicion for PVB19 infection in patients with anemia in the posttransplant phase, especially in patients on higher doses of immunosuppressants. Early and proper treatment can prevent worsening clinical condition and possible effects on the allograft.

Pure red cell aplasia in a simultaneous pancreas-kidney transplantation patient: inside the erythroblast

A case of pure red cell aplasia in a simultaneous kidney-pancreas transplant recipient on immunosuppressive therapy is reported here. The patient presented with anemia unresponsive to erythropoietin treatment. Bone marrow cytomorphology was highly suggestive of parvovirus pure red cell aplasia, which was confirmed with serology and polymerase chain reaction positive for parvovirus B19 DNA in peripheral blood. After the administration of intravenous immunoglobulin the anemia improved with a rising number of the reticulocytes.

[Parvovirus B19 infection after kidney transplantation]

Prevalence for human parvovirus B19 infection is estimated to be between 2% and 30% in renal transplant recipients. In post-transplant settings, parvovirus B19 infection may occur either as a primary infection or a reactivation. Parvovirus transmission most commonly occurs through respiratory tract but may also result from graft or blood packs contamination. Co-infections with HHV-6 and CMV viruses are frequent. The hallmark symptom is anemia, more rarely pancytopenia and hemophagocytic syndrome. In respect to renal involvement, parvovirus B19 infection has been associated with graft dysfunction in 10% of cases. Both thrombotic microangiopathies and collapsing glomerulopathies have been reported concomitantly with parvovirus B19 infection but the causal link remains unclear. Other complications are seldomly reported, including hepatitis, encephalitis, and myocarditis. Diagnosis is based on pre and post-transplant serological status. In addition, the management of parvovirus B19 infection in immunocompromised patients requires quantitative assessment of blood viral load by PCR. The treatment relies primarily on reduction of immunosuppression combined with intravenous immunoglobulin infusions. Relapses occur in 30% of cases.

Pure Red Cell Aplasia due to B19 Parvovirus Infection after Autologous Stem Cell Transplantation

Parvovirus B19 is recognized as a rare cause of pure red cell aplasia (PRCA) in allogeneic stem cell (SCT) and solid organ transplant patients. We report a patient with Hodgkin's disease who developed PRCA due to parvovirus B19 after autologous SCT and who had an excellent response after treatment with gamma-globulin.