Parvovirus b19 associated hepatitis

Abstract

Parvovirus B19 infection can present with myriads of clinical diseases and syndromes; liver manifestations and hepatitis are examples of them. Parvovirus B19 hepatitis associated aplastic anemia and its coinfection with other hepatotropic viruses are relatively underrecognized, and there is sufficient evidence in the literature suggesting that B19 infections can cause a spectrum of liver diseases from elevation of transaminases to acute hepatitis to fulminant liver failure and even chronic hepatitis. It can also cause fatal macrophage activation syndrome and fibrosing cholestatic hepatitis. Parvovirus B19 is an erythrovirus that can only be replicate in pronormoblasts and hepatocytes, and other cells which have globosides and glycosphingolipids in their membrane can also be affected by direct virus injury due to nonstructural protein 1 persistence and indirectly by immune mediated injury. The virus infection is suspected in bone marrow aspiration in cases with sudden drop of hemoglobin and onset of transient aplastic anemia in immunosuppressed or immunocompetent patients and is confirmed either by IgM and IgG positive serology, PCR analysis, and in situ hybridization in biopsy specimens or by application of both. There is no specific treatment for parvovirus B19 related liver diseases, but triple therapy regimen may be effective consisting of immunoglobulin, dehydrohydrocortisone, and cyclosporine.

Figure 1

Diagrammatic representation of spectrum of liver diseases associated with parvovirus B19 infection according to the severity.

Figure 2

Liver biopsy showing features of acute cholestatic hepatitis (H&E, 200x). The patient was a case of thalassemia trait, and parvovirus B19 IgM serology was positive.

Figure 3

(a) Parvovirus B19 inclusion in Pronormoblast in bone marrow aspirate (Geimsa, 1000x), in same case as described above. (b) Clearing of nuclei in pronormoblasts, due to Parvovirus B19 inclusion (HE, 400x); an adult case of hereditary spherocytosis with acute hepatitis and sudden drop of haemoglobin, Parvovirus IgM serology positive.

Figure 4

Schematic presentation of direct and indirect hepatocellular injury in parvovirus B19 infection.