Dhanya Mohan
Dubai Hospital, UAE
Title: Refractory anemia due to parvovirus b19 infection in a renal transplant recipient
Biography
Biography: Dhanya Mohan
Abstract
Post transplant anemia is a common occurrence in kidney transplant recipients (KTRs). Common etiologies include ineffective erythropoietin, drug related erythroid suppression, iron deficiency and infections. Parvovirus B19 infection, though rare, needs to be always considered in the work up of chronic anemia in KTRs, especially in those patients with reticulocytopenia. A 36-year-old Arab male patient underwent living unrelated donor transplantation because of end-stage-renal disease resulting from diabetic nephropathy. He received induction therapy with anti-thymocyte globulin and maintenance with prednisolone, tacrolimus and mycophenolate mofetil (MMF). Allograft function was stable with serum creatinine around 1 mg/ dl. Eighteen months after transplantation, he was detected to have anemia and leucopenia (Hb: 7.3gm/ dl, WBC: 3500/ cc). Blood film revealed microcytosis. Bicytopenia was initially attributed to mycophenolate and the dosage was reduced. Over the next four months, he had recurrent admissions with severe anemia, requiring six units of packed red cell transfusion. Hemoglobin ranged from 4.6- 5.7 gm/ dl. Reticulocyte count varied from 0.41%- 2.22%. Folic acid and B12 levels were unrevealing. CMV DNA PCR was negative. The low reticulocyte count prompted us to consider pure red cell aplasia as a cause for the anemia. Further serologic evaluation was positive for anti parvovirus B19 Ig M, and PV B19 DNA PCR in blood was positive. He received five doses of intravenous immunoglobulin, 400mg/kg body weight daily. Dose of MMF was reduced and tacrolimus level maintained between 4-6 ng/ ml. Hemoglobin improved to 10.8 gm/ dl within a month, and has stabilized at 14 gm/ dl ever since. His clinical follow–up during the subsequent two years has not shown recurrence of anemia, though PV virus levels are just above detection threshold. Parvovirus B19 is a single stranded DNA virus, which has a pronounced tropism for erythroid precursor cells. PV B19 infection is a well-known cause of pure red cell aplasia and should be included in the workup of refractory anemia in KTRs, when more common causes have been excluded. Treatment includes reduction of immunosuppression and administration of intravenous immunoglobulin in severe cases.