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Transient anticardiolipin antibody syndrome in a patient with parvovirus b19 infection

      To the Editor
      Transient autoantibodies are often produced in response to viral infections (
      • Hansen K.E.
      • Arnason J.
      • Bridges A.J.
      Autoantibodies and common viral illnesses.
      ,
      • Phillips P.E.
      Viral arthritis.
      ). Although these autoantibodies are usually polyspecific and occur in low titers, some patients develop high-titer antibodies with subtype specificity.
      Human parvovirus B19 causes several clinical syndromes including erythema infectiosum, polyarthritis, hepatitis, autoantibody expression, and aplastic crises in patients with hemolytic anemia or hemoglobinopathies (
      • Naides S.J.
      Rheumatic manifestations of parvovirus B19 infection.
      ,
      • Cohen B.
      Parvovirus B19 an expanding spectrum of disease.
      ). Anticardiolipin antibodies have been reported infrequently in adults infected with parvovirus B19. We report a patient with transient anticardiolipin antibody syndrome and thrombosis after human parvovirus B19 infection.
      A 25-year-old previously healthy man was admitted with left upper-quadrant abdominal pain and a 2-week history of fever. Physical examination revealed a fever of 38.8°C and tender splenomegaly. There was no hepatomegaly or lymphadenopathy, and no other abnormalities were noted.
      Splenomegaly (and the absence of hepatomegaly) were confirmed with an abdominal ultrasonography examination. Persistent abdominal pain and worsening splenomegaly prompted a second ultrasound examination with duplex, which revealed a wedge-shaped lesion in the spleen consistent with an infarct and reversed flow in one of the branches of the splenic vein. There was no evidence of thrombosis in the hepatic vein or the main splenic vein. A computed tomographic scan of the abdomen confirmed the infarct area in the spleen and showed mild retroperitoneal lymphadenopathy.
      Laboratory studies disclosed normal levels of antithrombin-III, protein C and protein C resistance, protein S, and homocysteine, and elevated titers of anticardiolipin antibody IgG (104 gpl/mL) and IgM (56 mpl/mL). Two weeks after presentation, further tests were strongly positive for IgM antibodies and slightly positive for IgG antibodies for parvovirus B19. There was no evidence of IgM antibodies for cytomegalovirus or Epstein-Barr virus infections.
      The patient’s condition was diagnosed as acute parvovirus B19 infection with the anticardiolipin antibody syndrome. He was treated with aspirin (100 mg per day) and his fever and upper abdominal pain resolved. An abdominal ultrasonography examination revealed normal flow in the splenic vein. Repeat tests 1 and 2 months later showed decreases in the titers of IgG and IgM anticardiolipin antibodies.
      The natural history of human parvovirus B19 infection is biphasic, consisting of a viremic phase and an antibody response phase (
      • Naides S.J.
      Rheumatic manifestations of parvovirus B19 infection.
      ). Some patients are asymptomatic; others have a flulike illnesses. The onset of anti-B19 IgM antibodies is associated with clearance of viremia, and the second phase of the illness is frequently characterized by rash, arthralgia, or arthritis, and less frequently by autoantibodies in the blood (
      • Naides S.J.
      Rheumatic manifestations of parvovirus B19 infection.
      ,
      • Ytterberg S.R.
      Viral arthritis.
      ,
      • Golstein M.A.
      • Steinfeld S.
      Semaille P
      Rheumatic manifestations due to human parvovirus B19. A report of four cases..
      ).
      Moore et al (
      • Moore T.L.
      • Band Lamudi R.
      • Alam S.M.
      • Nesher G.
      Parvovirus infection mimicking systemic lupus erythematosus in a pediatric population.
      ) reported 7 patients with parvovirus B19 infection who had a history of malar rash and arthralgia. Six of these patients had antinuclear antibodies, of whom 2 had antibodies to Scl-70, and 4 had antibodies to Sm, RNP, SS-A (Ro), or SS-B (La). Two patients presented with elevated levels of rheumatoid factor, and all had an elevated IgM antibody titer to parvovirus B19 at the onset of their illness. Hansen et al (
      • Hansen K.E.
      • Arnason J.
      • Bridges A.J.
      Autoantibodies and common viral illnesses.
      ) reported a 54-year-old woman who presented with a history of febrile disease and diffuse pruritic rash. Laboratory studies showed evidence of anticardiolipin IgG and IgM. Further investigation revealed IgM antibodies to parvovirus B19.
      Anticardiolipin antibodies have been found in a variety of viral illnesses. In one study (
      • Colaco C.B.
      • Mackie I.J.
      • Irving W.
      • Machin S.J.
      Anticardiolipin antibodies in viral infection.
      ), 40 patients with acute viral infection were tested for anticardiolipin antibodies by enzyme-linked immunosorbent assay. Eight of 10 patients with parvovirus B19 infection, 7 of 10 with Epstein-Barr virus infection, 10 of 10 with hepatitis A virus infection, and 8 of 10 with rubella had anticardiolipin antibodies.
      Infection with parvovirus B19 may be associated with the expression of various autoantibodies and clinical events, as in our patient. In patients with prolonged febrile illness and symptoms of connective tissue disease, testing for parvovirus B19 antibodies may be helpful in differentiating between transient illness and connective tissue disease and in making decisions about patient management.

      References

        • Hansen K.E.
        • Arnason J.
        • Bridges A.J.
        Autoantibodies and common viral illnesses.
        Semin Arthritis Rheum. 1998; 27: 263-271
        • Phillips P.E.
        Viral arthritis.
        Curr Opin Rheum. 1997; 9: 337-344
        • Naides S.J.
        Rheumatic manifestations of parvovirus B19 infection.
        Rheum Dis Clin North Am. 1998; 24: 375-401
        • Cohen B.
        Parvovirus B19.
        BMJ. 1995; 311: 1549-1552
        • Ytterberg S.R.
        Viral arthritis.
        Curr Opin Rheum. 1997; 11: 275-280
        • Golstein M.A.
        • Steinfeld S.
        • Semaille P
        Rheumatic manifestations due to human parvovirus B19. A report of four cases..
        Rev Rheum Engl Ed. 1996; 63: 854-858
        • Moore T.L.
        • Band Lamudi R.
        • Alam S.M.
        • Nesher G.
        Parvovirus infection mimicking systemic lupus erythematosus in a pediatric population.
        Semin Arthritis Rheum. 1999; 28: 314-318
        • Colaco C.B.
        • Mackie I.J.
        • Irving W.
        • Machin S.J.
        Anticardiolipin antibodies in viral infection.
        Lancet. 1989; 1: 622