Nosocomial Transmission of Parvovirus B19 Infection in Transplant Patients
Nosocomial Transmission of Parvovirus B19 Infection in Transplant Patients
Abstract & Commentary
Synopsis: This report shows that chronically infected transplant patients can be the source of a nosocomial outbreak among immunocompromised patients.
Source: Lui SL, et al. Nosocomial outbreak of parvovirus B19 infection
in a renal transplantation unit. Transplantation. 2001;71:59-64.
A 52-year-old woman undergoing intensive immunosuppressive treatment for renal allograft rejection developed severe anemia (hemoglobin 6 g) with < 0.1% reticulocytes. Bone marrow biopsy showed decreased erythropoiesis with giant pronomoblasts, consistent with parvovirus B19 infection. This was confirmed by detection of viral DNA in serum by PCR. She was given 2 courses of IVIG without response, and she subsequently died of Gram-negative sepsis. Two renal transplant patients who had been hospitalized on the unit during the first patient’s hospitalization developed parvovirus B19 infection characterized by severe anemia and presence of viral DNA in serum. One of these patients was being treated for graft rejection. A 5-day course of IVIG led to transient hematologic and virologic improvement; a second course was followed by recovery of serum hemoglobin levels to normal and clearance of viremia. The third patient was receiving maintenance immunosuppression only and recovered spontaneously.
Although all 3 patients were hospitalized simultaneously on the same unit, they were never roommates. Viral DNA sequences obtained from the sera of the 3 patients were identical, and were distinct from those found in 7 community acquired cases. None of the unit staff had clinical or virologic evidence of acute infection.
Comment by Robert Muder, MD
Parvovirus B19 is a DNA virus that causes Fifth disease, a common childhood exanthem characterized by fever and rash. Person-to-person transmission most likely occurs via respiratory droplets during the prodromal or early symptomatic phase of the illness. Adults acquiring the infection (typically after contact with infected children) may develop acute polyarthritis, often without typical rash.
The virus specifically infects red-cell precursors in the marrow and profoundly depresses red cell production during acute infection. In a healthy child or adult, interruption of hematopoiesis for several days is without significant consequences. However, patients with chronic hemolytic anemias may have dramatic drops in circulating red cells. Parvovirus B19 is the most frequently identified cause of aplastic crisis in patients with sickle-cell disease. As patients with sickle-cell disease are immunologically normal, the infection is self limited. Transfusion to maintain adequate hemoglobin levels until spontaneous recovery occurs is usually sufficient.
Patients who are immunosuppressed, including those with HIV infection or organ transplantation, may have chronic infection with severe, refractory anemia and prolonged viremia. IVIG may be effective in reducing viremia and permitting resumption of hematopoiesis. The therapeutic effect may be temporary, and repeat courses of treatment may be required. The cases reported by Lui and colleagues demonstrate the spectrum of disease in the immunocompromised. This may include refractory infection, infection responsive to 1 or more courses of IVIG, or spontaneous recovery.
Nosocomial outbreaks of parvovirus B19 have been reported among immunocompetent patients and hospital staff. The current report illustrated that chronically infected transplant patients can be the source of a nosocomial outbreak among immunocompromised patients. The index patient had been infected for approximately 2 months before the second-case patient was admitted to the unit. There was no documentation of direct contact among the involved patients, and the mode of transmission is not certain. However, parvovirus B19 is excreted in respiratory secretions and urine of infected patients. It is a particularly hardy virus. It is fairly resistant to killing by heat and physical agents, and it can persist in the environment for prolonged periods. Indirect contact transmission therefore seems likely. It would seem prudent to isolate hospitalized patients with acute or chronic parvovirus B19 infection, particularly if they are housed on a unit with immunocompromised patients.
Additional Reading
1. John JF. Parvovirus and leukopenia. Infectious Disease Alert. 2000;19:179-180.
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