Evaluation of serological assays for identification of parvovirus B19 immunoglobulin M

A Retrospective Analysis of Clinical and Epidemiological Aspects of Parvovirus B19 in Brazil: A Hidden and Neglected Virus Among Immunocompetent and Immunocompromised Individuals

Parvovirus B19 (B19V) infection can affect individuals of all ages, both immunocompetent and immunocompromised. This infection is typically acute and self-limiting, most commonly resulting in rash diseases and acute febrile illness. However, its involvement in atypical manifestations such as chronic kidney disease and acute liver failure have also been reported. Diagnosis of B19V is rarely conducted in these populations, and available studies on its prevalence are limited, outdated, and do not accurately depict the current situation. This study describes and discusses retrospective investigations into the role of B19V in cases of rash diseases, acute febrile illness, anemia, occurring in the context of chronic kidney disease and HIV coinfection, and acute liver failure when no identifiable etiological agent was found, focusing on various populations in Brazil. This overview underscores the importance of recognizing the potential for severe B19V infection in all individuals, regardless of perceived immune status, as well as of considering the possibility of B19V concurrent infection, in both high-risk groups and healthy individuals to reduce the risk of serious complications and improve patient outcomes, by considering the inclusion of B19V in the routine of diagnosis and implementing management strategies. This study was limited by the absence of national surveillance data of B19V in Brazil and by the analyses that occurred retrospectively.

"Parvovirus B19-related Acute Hepatitis: Clinical Spectrum and Outcome in Children"

BACKGROUND/AIMS

Acute liver injury is a common manifestation of parvovirus B19 (PVB19) infection in immunocompromised patients. However, literature in immunocompetent children is scarce. We aimed to study the clinicolaboratory features and outcome of hepatic involvement by PVB19 infection in hospitalized children.

METHODS

We retrospectively analyzed our prospectively kept database of all children (<18 years old) admitted with acute viral hepatitis (AVH), acute liver failure (ALF) or acute-on-chronic liver failure (ACLF), and PVB19 infection between January 2010 and December 2023. Clinical features, laboratory parameters, and complications were evaluated. Poor outcome was defined as death or liver transplantation.

RESULTS

A total of 35 children (19 boys [54%], median age: 7.25 [interquartile range: 4-10.8] years) with PVB19-related hepatitis were studied (28 [80%] isolated PVB19 infection and 7 [20%] coinfections [3 with Epstein-Barr virus, 2 with hepatitis A, and 1 each with hepatitis-E and cytomegalovirus]). AVH (17, 49%) was the most common presentation, followed by ALF (13, 37%) and acute insult in ACLF (5, 14%). Patients with coinfection had significantly higher bilirubin (14.6 [9.4-21.5] vs 6.8 [4.3-10.9] mg/dl; P=0.004) and transaminases (ALT: 697 [428-1296] vs. 277 [157-478] U/L; P=0.02) but similar mortality (1/7 vs 6/23; P=1.0) than PVB19 alone. Nine cases (25.7%) had extrahepatic complications (hemophagocytic lymphohistiocytosis [HLH]: 3, acute kidney injury: 3, aplastic anemia: 2, and myocarditis: 1). Poor outcome occurred in 38% (5/13) ALF, 11.7% (2/17) AVH (HLH: 1, myocarditis: 1), and none (0/5) of the ACLF cases.

CONCLUSION

PVB19 should be considered in children presenting with indeterminate acute liver injury, especially in younger children or those with complications such as aplastic anemia, HLH, or myocarditis.

Parvovirus B19 Is Associated with a Significant Decrease in Hemoglobin Level among Children <5 Years of Age with Anemia in Northwestern Tanzania

Parvovirus B19 (B19) can cause transient aplastic crisis and lead to acute severe anemia. This study investigated the relationship between B19 and anemia among children <5 years old in the city of Mwanza, Tanzania. An enzyme immunoassay was used to detect B19 IgM- and IgG-specific antibodies among children with various categories of anemia according to the World Health Organization (WHO) guidelines. A total of 265 children with median age of 28.5 months (interquartile range 18-39.5) were investigated. Eighty-six children (32.5%) had severe anemia. B19-specific IgM and IgG antibodies were detected in 24 (9%) and 46 (17.4%) children, respectively. Low hemoglobin (Hb) level (p = 0.031), Plasmodium falciparum infection (p = 0.001) and residing in rural areas (p = 0.025) independently predicted B19 IgM seropositivity. Acute B19 infection decreased Hb level by 1.1 g/dl (p = 0.003). In malaria endemic areas, acute B19 infections should be considered among children with severe anemia from rural areas.

Genotypes of erythrovirus B19, their geographical distribution & circulation in cases with various clinical manifestations

Erythrovirus B19 (B19V) is one of the erythroviruses known to be pathogenic in humans. B19V is classified into three distinct genotypes; 1, 2 and 3, differing from each other by 2-13 per cent. Genotype 1 consists of the prototype B19V isolates, genotype 2 comprises the A6, LaLi and their related isolates while genotype 3 includes the V9- and V9-related isolates. The classification of genotype 1 into two subtypes (1A and 1B) and genotype 3 into two subtypes (3a and 3b) with an estimated nucleotide difference of about 5 per cent has been done. Predominance of genotype 1 across all the continents is seen followed by genotypes 2 and 3. There are no disease-specific genotypes. All the three genotypes have been found in symptomatic as well as asymptomatic individuals and have been reported from several countries across the world. The prevalence of genotype 2 in older populations and its absence from current circulation in Northern Europe has also been reported. The present review focuses on geographic distribution and association of genotypes of B19V with different clinical manifestations.

Parvovirus B19 infection in human pregnancy

Human parvovirus B19 infection is widespread. Approximately 30-50% of pregnant women are nonimmune, and vertical transmission is common following maternal infection in pregnancy. Fetal infection may be associated with a normal outcome, but fetal death may also occur without ultrasound evidence of infectious sequelae. B19 infection should be considered in any case of nonimmune hydrops. Diagnosis is mainly through serology and polymerase chain reaction. Surveillance requires sequential ultrasound and Doppler screening for signs of fetal anaemia, heart failure and hydrops. Immunoglobulins, antiviral and vaccination are not yet available, but intrauterine transfusion in selected cases can be life saving.

Advances in the biology, diagnosis and host-pathogen interactions of parvovirus B19

Increased recognition of parvovirus B19 (B19), an erythrovirus, as a significant human pathogen that causes fetal loss and severe disease in immunocompromised patients has resulted in intensive efforts to understand the pathogenesis of B19-related disease, to improve diagnostic strategy that is deployed to detect B19 infection and blood-product contamination and, finally, to elucidate the nature of the cellular immune response that is elicited by the virus in diverse patient cohorts. It is becoming clear that at least three related erythrovirus strains (B19, A6/K71 and V9) are circulating in the general population and that viral entry into target cells is mediated by an expanding range of cellular receptors, including P antigen and beta-integrins. Persistent infection by B19 is emerging as a contributory factor in autoimmune disease, a hypothesis that is constrained by the detection of B19 in the skin of apparently healthy individuals. B19 infection during pregnancy may account for thousands of incidences of fetal loss per annum in Europe, North America and beyond, yet there is currently only minimal screening of pregnant women to assess serological status, and thereby risk of infection, upon becoming pregnant. Whilst major advances in diagnosis of B19 infection have taken place, including standardization of serological and DNA-based detection methodologies, blood donations that are targeted at high-risk groups are only beginning to be screened for B19 IgG and DNA as a means of minimizing exposure of at-risk patients to the virus. It is now firmly established that a Th1-mediated cellular immune response is mounted in immunocompetent individuals, a finding that should contribute to the development of an effective vaccine to prevent B19 infection in selected high-risk groups, including sickle-cell anaemics.

Parvovirus B19 infection in medical students during a hospital outbreak

From March to May 2002, a parvovirus B19 (B19) outbreak was identified at a general hospital that serves as a teaching facility for the Universidad Autónoma de San Luis Potosí, Mexico. Medical students attending the hospital presented with symptoms suggestive of B19 infection. Previous studies have suggested that apparent hospital-related B19 outbreaks may be a reflection of B19 infection in the community. A study was undertaken to assess whether exposure to the hospital was a risk factor for B19 infection and to determine to what extent medical students were infected during this outbreak. The incidence of B19 infection in medical students attending the teaching hospital during the outbreak (n = 211) was determined and compared to students not attending the hospital (n = 96). To assess if a community-wide outbreak had occurred, 80 blood donors were also evaluated for the presence of B19 antibodies. Acute B19 infection was identified in 40 of 119 (33.6 %) susceptible students attending the hospital and in 20 of 47 (42.6 %) susceptible students not attending the hospital. The frequency of acute infection among susceptible blood donors was lower (9.5 %) than in students, but higher than the rate expected during non-epidemic periods. Most infections (68.3 %) were asymptomatic. Symptoms reported by infected subjects were not specific for B19 infection. Only 11.7 % of subjects with acute infection fulfilled the clinical surveillance definition used to detect cases during the outbreak. In conclusion, hospital exposure was not associated to increased risk of B19 infection among medical students. Medical students may be at increased risk for acquiring and transmitting B19 infection during outbreaks.

Mumps-like syndrome owing to parvovirus B19: a brief report

Major manifestations of acute parvovirus B19 infection are usually erythema infectiosum, transient aplastic crisis and polyarthropathy. We report a case suspected to have mumps-meningo-encephalitis who had IgM and IgG antibodies positive for parvovirus B19.

Human parvovirus B19 infection in patients with systemic lupus erythematosus

OBJECTIVE

The clinical significance of the presence of B19 DNA in patients with SLE was studied.

METHODS

Sera from 72 patients with systemic lupus erythematosus (SLE), 23 patients with rheumatoid arthritis (RA), 18 patients with Sjögren's syndrome (SS), eight patients with Raynaud's phenomenon (RP), five patients with primary biliary cirrhosis (PBC), five patients with polymyositis (PM), four patients with erythema infectiosum (EI) and 22 normal controls were examined for parvovirus B19 (B19) infection by serological assays, nested PCR and Southern blotting.

RESULTS

Parvovirus B19 DNA was detected in 17 of 72 patients with SLE and in three of four patients with EI, but not in patients with other systemic rheumatic diseases. Of the 17 patients with B19 DNA, only one had IgG anti-B19 antibody and two had IgM anti-B19 antibodies, whereas IgG and IgM anti-B19 antibodies were detected in 27 (49.1%) and 21 (38.2%) of 55 SLE patients without B19 DNA respectively. All sera from the patients with EI contained both IgG and IgM anti-B19 antibodies. B19 DNA was found more commonly in sera from SLE patients without anti-B19 antibodies than in those with anti-B19 antibodies (P<0.05).

CONCLUSIONS

B19 infection in patients with SLE may be due to lack of anti-B19 antibodies because of either the immunocompromised nature of the host or the use of immunosuppressive drugs. There was a higher prevalence of hypocomplementaemia and RP in patients with parvovirus B19 viraemia than in those without parvovirus B19 viraemia.

Detection of parvovirus B19 IgM by antibody capture enzyme immunoassay: receiver operating characteristic analysis

Parvovirus B19 infection can cause severe effects in high-risk groups including pregnant women and immunocompromised individuals. Although serological detection of B19 infection is commonplace, minimal information is available on the absolute performance characteristics of various tests for the detection of B19 IgM. The performance of the first parvovirus B19 IgM enzyme immunoassay to be cleared by the US Food and Drug Administration (FDA) is described. The immunoassay cut-off has been established using receiver operating characteristic (ROC) analysis giving a sensitivity and specificity of detection of 89.1 and 99.4%, respectively. No cross-reactivity is observed with rubella or other viral disease IgM which cause similar symptomologies to parvovirus B19. Multi-site reproducibility studies have shown high immunoassay reproducibility with detection rates (observed/expected result) of 100% for nonreactive specimens (N=324) and strongly reactive (N=403), respectively. Immunoassay reproducibility ranged from 11.76 to 17. 46% coefficient of variation for all reactive specimens tested (N=12) whereby each specimen was assayed a total of 81 times. Parvovirus B19 IgM seroprevalence of 1% was observed in a US blood donor population (N=399). In the absence of international performance criteria, this study will be of major benefit to the clinical virologist in assessing immunoassay reliability for the detection of recent infection with parvovirus B19.

Serologic study of human parvovirus B19 infection in pregnancy in Japan

OBJECTIVES

To clarify the relationship between hydrops fetalis and parvovirus outbreaks in the community, seroprevalence of B19 antibody among women of childbearing age, and adverse effects of intrauterine B19 infection.

METHODS

Sera were collected from 168 cases of hydrops fetalis which were diagnosed between 1987 and 1997 in Miyagi prefecture, Japan, from 232 healthy pregnant women in 1987 and 277 healthy pregnant women in 1997 in Miyagi, and from 48 women infected with B19 during pregnancy. The sera were examined for B19 IgG and IgM antibodies by enzyme-linked immunosorbent assay and for B19 DNA by polymerase chain reaction. The number of cases of erythema infectiosum in Miyagi had been monitored each month.

RESULTS

Thirteen of the 168 cases of hydrops fetalis were found to be caused by intrauterine B19 infection and 12 of the 13 cases clustered in two periods of outbreaks of erythema infectiosum in the community. The positive rates of B19 IgG antibody between 1987 and 1997 were significantly different: 33% in 1987 and 46% in 1997. Nine of the 48 women infected during pregnancy showed adverse effects of the fetus: eight hydrops fetalis and one early abortion with positive B19 DNA. The fetal death rate (>12 weeks of gestation) among them was 15% (7/48), far higher than the calculated 1% among the general population. The nine mothers with adverse fetal outcomes had contact with the infectious source at the 16 weeks of gestation or earlier.

CONCLUSIONS

These data clearly showed a relationship between hydrops fetalis and parvovirus outbreaks in the community, and it may be important to follow the seroprevalence for an extrapolated period time to predict occurrence of hydrops fetalis caused by B19. Also the data indicated that the gestational week infection occurred is the most important determinant of an adverse effect to the fetus as described previously.

Parvovirus B19 infections in pregnancy

Parvovirus B19 is the viral agent that causes the childhood exanthum erythema infectiosum, or fifth disease. Approximately 50% of pregnant women are seropositive for this agent and thus immune to primary infection. However, acute infection may develop in seronegative pregnant women exposed to B19. Acute B19 infections during pregnancy have been associated with miscarriage and hydrops fetalis. This latter condition is amenable to fetal therapy via intrauterine transfusion.

Detection of parvovirus B19-specific IgM by antibody capture radioimmunoassay

A solid phase IgM-capture radioimmunoassay (MACRIA) for the detection of parvovirus B19-IgM is described (Cohen et al., 1983, J. Hyg. Camb. 91, 113-130). IgM from a dilution of patients serum is 'captured' onto a solid phase coated by anti-human IgM. To determine whether any of the IgM is specific for parvovirus B19, B19 antigen is added followed by a detector system. In the MACRIA described here the detector system comprises a mouse monoclonal antibody to parvovirus B19 and a 125I-labelled anti-mouse antibody. A calibration curve derived from a standard B19 IgM serum is used to quantify B19 IgM using a single dilution of test sera. The purpose of the protocol is the diagnosis of recent acute infection with parvovirus B19.