Rev. Bras. Reumatol. vol.55 número2

rev bras reumatol.2015;55(2):185–188

w w w . r e u m a t o l o g i a . c o m . b r

REVISTA

BRASILEIRA

DE

REUMATOLOGIA

Case

report

Parvovirus

B19

infection

as

a

cause

of

acute

myositis

in

an

adult

Mustafa

Cakirca

_,

_Cumali

_Karatoprak

_,

_Serdal

_Ugurlu

,

Mehmet

Zorlu

,

Muharrem

Kıskac¸

_,

_Güven

_C¸

_etin

a_{DepartmentofInternalMedicine,MedicalFaculty,BezmialemVakifUniversity,Istanbul,Turkey}

b_{DivisionofRheumatology,DepartmentofInternalMedicine,CerrahpasaMedicalFaculty,UniversityofIstanbul,Istanbul,Turkey}

c_{DivisionofHematology,DepartmentofInternalMedicine,MedicalFaculty,BezmialemVakifUniversity,Istanbul,Turkey}

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Articlehistory:

Received19January2013 Accepted23June2013

Availableonline26November2014

Keywords: ParvovirusB19 Acuteadultmyositis Fever

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ParvovirusB19infectionisoftenasymptomatic,butclinicalexpressionsmayinclude tran-sientaplasticcrisis,erythemainfectiosum,non-immunehydropsfetalis,andchronicred cellaplasia.Thisvirushasalsobeenassociatedwithrheumatoidarthritisandother autoim-muneconnectivetissuediseases;however,wecouldnotidentifyanyacuteadultmyositis casedevelopedafteraParvovirusB19infectionintheliterature.Forthisreason,wewould liketopresentararecaseofacutemyositisdevelopedafterParvovirusB19infection.In patientspresentingwithsymptomsoffever,rashonthelegsandmyositis,viralinfections suchasParvovirusB19shouldbekeptinmind.

©2014ElsevierEditoraLtda.Allrightsreserved.

Infecc¸ão

por

parvovírus

B19

como

causa

de

miosite

aguda

em

um

adulto

Palavras-chave: ParvovírusB19

Miositeagudadoadulto Febre

r

e

s

u

m

o

A infecc¸ão pelo ParvovírusB19costuma serassintomática,mas asexpressões clínicas podemincluircriseaplásticatransitória,eritemainfeccioso,hidropisiafetalnãoimunee aplasiacrônicadasérievermelha.Essevírustambémseassociaàartritereumatoideea outrasdoenc¸asautoimunesdotecidoconjuntivo;entretanto,nãoconseguimosidentificar naliteraturanenhumcasodemiositeagudaemadultodesenvolvidadepoisdeinfecc¸ãopelo ParvovírusB19.Poressarazão,gostaríamosdeapresentarumcasorarodemiositeaguda desenvolvidadepoisdeinfecc¸ãopeloParvovírusB19.Nospacientesqueapresentam sin-tomasdefebre,rashnaspernasemiosite,devemserconsideradasasinfecc¸õesvirais,como acausadapeloParvovírusB19.

©2014ElsevierEditoraLtda.Todososdireitosreservados.

∗ _{Correspondingauthor.}

E-mail:serdalugurlu@gmail.com(S.Ugurlu). http://dx.doi.org/10.1016/j.rbre.2014.10.001

186

Introduction

ParvovirusB19(B19),anon-enveloped22–26nmicosahedral single-stranded DNA virus discovered in 1975, is the only memberofthefamilyParvoviridaeknowntobepathogenic tohumans.1_{Thisinfectiousdiseaseisgenerallyseenduring} childhood, but rarely in adults. Infection appears to con-ferlifelongimmunityinimmunocompetenthosts.Although theseroprevalenceishigh,viremiaorpresenceofviralDNA in peripheral blood is rare in healthy individuals.2 _{B19 is} transmittedthrough the respiratory route, but can also be transmittedvertically from mother to fetus,through bone marrowandorgantransplantations,andviatransfusedblood products.2_{MostcasesofB19infectionsareasymptomaticand} resolvespontaneouslyinadults.ButsometimesB19causesa transientaplasticcrisis,erythema-infectiosum(fifthdisease), non-immunehydropsfetalisandchronicredcellaplasia.This virushasalsobeenassociatedwithrheumatoidarthritisand otherautoimmuneconnectivetissuediseases;3_however,we couldnotidentifyanyacuteadultmyositiscasesdeveloped afterB19infection.Intheliterature,forthatreason,wewould liketopresentararecaseofacutemyositisdevelopedafter B19infection.

Case

report

A 38-year-old male patient was admitted to the internal medicinepolyclinicwithcomplaintsofhighfeverandmalaise. These,plusdiffusepain,hadstarted3daysbeforeandbecame increasinglysevere.Hehadnohistoryofdiseasesormedicine use.Inthephysicalexamination,hisauxiliarybody tempera-turewas39◦_{C,andothersystemicexaminationswerenormal.}

The laboratory tests revealed increased levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), andC-reactiveprotein(CRP).Leukopenia,thrombocytopenia, and monocytosis were foundinhishemogram(Table1).A slight increase in monocytes was found in his peripheral bloodsmear.Bloodculturetakenduringhishighfeverperiod showednogrowth.Heterophileantibody(monospot)was neg-ative.

Maculopapularrashesdevelopedunderbothkneesbuthis fever decreased within the next 2 days. B19 antibodyIgM testedpositive,andthusB19wasconsideredtobethecause oftherashes.Onthethirddayofthedisease,arthralgia devel-opedinbothankles,andalsoinbothhands.Onthesixthday, therashesremitted,replacedbypaininbothcalvessosevere thatitpreventedhimfromwalking.

Intheinvestigationsperformedforthefollow-up,AST,ALT and creatinekinase (CK) were found to havedecreased to withinnormalranges,butCRPanderythrocytesedimentation rates (ESH)had increased(Table 1). Thepatient was hospi-talized,andnaproxensodium1100mg/daywasinitiated.The bilateralcrurisMRItakenduetocontinuingseverepainonhis bilateralcalfmusclesrevealedthickeningandedemainboth gastrocnemiusandthesemimembranosusmusclegroup,an increasedsignalinT2,and anedematousappearance.The minimalcontrastinvolvementinthepost-contrastserieswas consideredtobemyositis(Fig.1).Follow-uponthe10thday ofthetreatmentrevealedreducedpain,andESHandCRPhad returnedtowithintheirnormalranges.

Discussion

B19iscommonworldwide,andtheseroprevalenceincreases withage,sothat15%ofpreschoolchildren,50%ofyounger

Table1–Testresultsofthepatient.

Test 1stday 3rdday 8thday 10thday 17thday Normalrange

AST(U/L) 67 37 28 30 16 10–50

ALT(U/L) 98 77.5 57.7 34 15–38

LDH(U/L) 260 254 246 190 0–225

CK(U/L) 149 52 51 39–308

CRP(mg/dL) 2.4 1.74 1.76 5.9 0–0.5

ESH(mm/h) 10 42 90 <15

WBC(×103/mm3/␮L) 3.73 5.35 6 7.02 3.8–10

Neutrophils(%) 40.5 59 55 40 50–80

Lymphocytes(%) 26.8 25 29 43 10–48

Monocytes(%) 28 9.7 12 12.7 2–10

HGB(g/dL) 16.7 15.9 14.3 14.1 13–17.5

Platelets(×103/mm3/␮L) 123 124 274 321 142–424

ParvovirusB19IgM 76.9positive <9U

ParvovirusB19IgG 11.8 <9U

HerpesSimplexType1IgM 0.27 <1.1ratio

HerpesSimplexType1IgG >200 <22RU

HerpesSimplexType2IgM 0.16 <1.1

HerpesSimplexType2IgG <2 <22RU/mL

Ebstein–BarrvirusVCA-IgM 0.34 <1.1

Ebstein–BarrvirusVCA-IgG 84.86 <22RU/mL

rev bras reumatol.2015;55(2):185–188

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Fig.1–Bothlowerlimbs’MRIimagesofthepatient.

adultsandabout85%oftheelderlyshowserologicevidence ofpastinfection.2 _{Thisinfectiousdisease isgenerallyseen} duringchildhood,but rarelyinadults.Laboratorydiagnosis of B19 can be performed using serology, PCR, histopatho-logicexaminationandimmunohistochemistry.2_Theprecise diagnosis ofrecent or past infection with B19 dependson the use of enzyme immunoassays to detect anti-B19 IgM and IgG in plasma. To confirm acute B19 infection, IgM antibodiesmustbedetectedinplasmaorserum.These anti-bodies are synthesized approximately 7–10 days after the high-titer viremia.4 _{B19 IgG appears shortly after IgM and} persistslifelongwithslowlydecreasingtitersunlessboosted bysubsequent encounters withthe virus. Theclinical sig-nificance of different serum-titers ofB19 DNA is not fully established. In healthy individuals with acute B19 infec-tion, viral titers as high as 1012_{gEq/mL are detectable in} blood.3,4

Benignacutemyositisisaself-recovering[benign] condi-tioncharacterizedbyacutebilateralcalf painanddifficulty inwalkingthatusuallydevelopsinschool-agechildrenafter theyhaverecoveredfromviralinfections.Itwasfirst recog-nizedin1957byLundbergin74pediatricsubjects.5,6_Myositis casescoincidewithdermatomyositisandsystemiclupus ery-thematosusafterParvovirusB19infectioninadults.7_Although themostcommonviralcausesofacutemyositisareInfluenza A,B(including theH1N1 virus)and Coxsackievirusviruses inchildren,nocasereportwasfoundaboutB19associated with benign acute childhood myositis.8 _{However, there is} onecase report about myofacitis associatedwith B19 in a healthyadult.9 _{But, toour knowledge,literaturereportsno} casesaboutmyositisassociatedwithB19inanadult.Aswe knowB19infectionoccursespeciallyintransplantpatients, patients withsystemic diseases and immunocompromised patients.4 _{Inourcase,althoughtherewasnohistory of} ill-nessanddrugintake,historyofintensepaceofwork,intense stress and a 12-h trip might have a negative impact on immuneresistanceandmaycausemyositisassociatedwith B19.

Inourpatient,clinicalandlaboratoryfindings,magnetic resonance imaging and response to therapy support the diagnosis of acute myositis. The expected increased sedi-mentationand CRPwere found;however, theCKlevel had not increasedinour patient. Theabsence ofincreasedCK levels mayleadtoconfusion.From thepatient’s laboratory follow-up,wecouldseethatCKlevelwasthreetimeshigher inthefirstperiod.ButCKlevelwasnormalineveryperiod of the disease.Although most patients withinflammatory myopathies present with increased creatine kinase levels, reportedseriesincludesomepatientswithnormalcreatine kinaselevels.9–11_{Inthesecases,eventhoughmyopathywas} diagnosed by methods such as biopsy and MRI, CK levels were normal. Andconcrete evidencewas notsubmittedto explainthissituation.Inanarticlepresentingsevenpatients withmyositis,alackofcreatinekinaseelevationinpatients withmyositiswasfoundtobeapoorprognosticsign.10_Our case had a benign course and clinical findings improved quickly.

Despitethesimilaritywithchildhoodbenignacute myosi-tis cases,ourcasewasthoughttobeinterestingbecause it wasinanadultwithnoincreasedCKlevel.Inpatientswho present withfever,rashon thelegs, andmyositis(such as inourcase),viral infectionssuchasB19shouldbekeptin mind.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Acknowledgments

TheauthorsthankS.Delecroixfortranslationconsultancy.

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