MON-168 A CASE REPORT OF HUMAN PARVOVIRUS B19 INFECTION IN A RENAL TRANSPLANT PATIENT

Abstract

Anaemia after kidney transplant has been linked to infection by Parvovirus (PV) B19. Organ transplant patients can have the B19 virus persisting for years due to impairment of the neutralizing antibody response and/or cellular immunity. Up to 39% of kidney transplant (KT) recipients suffer from chronic anaemia. They may acquire symptomatic PV B19 infection from the donor, the community or from reactivation of endogenous latent or persistent virus. PV B19 infection in KT recipients tend to occur within a 6-month period after transplantation when the immuno-suppression (IS) is at the strongest. This case report describes a 49 year old Malay lady who has End Stage Renal Disease secondary to Systemic Lupus Erythematosus. She was on haemodialysis for 17 years before a deceased donor renal transplant in November 2017. Thymoglobulin was used as her induction agent and maintained with mycophenolate sodium (Myfortic) at 360 mg bd, tacrolimus and prednisolone. Her tacrolimus level ranges from 8 to 10 ng/ml. Her baseline haemoglobin (Hb) prior to the renal transplant was 9.7 g/dL. Post operation Hb ranging from 8.5 to 9 g/dL. Iron studies showed adequate iron stores with ferritin and transferrin saturation level of 770ug/L and 93% respectively. There was no evidence of hemolysis and the reticulocyte was 0.19%. Subcutaneous(SC) erythropoietin stimulating agent ( ESA) was started 2 weeks post operation to maintain her Hb level. Despite regular SC ESA injection, her Hb level did not improve and dropped 6 weeks after the operation and became pancytopenia. Her serum creatinine was 180 umol/L. SLE activity markers were negative . Pre-transplant immunoglobulin G (IgG) studies showed positivity to Cytomegalovirus (CMV). For the next 4 months, she required 3 to 4 pints of Red Blood Cells (RBC) transfusions monthly. Oesophagogastroduodenoscopy(OGDS) showed gastric erosion only. CMV PCR sent repeatedly were negative. In May 2018, Parvovirus PCR was found to be positive with positive IgG and negative IgM level. Bone marrow aspiration and trephine (BMAT) showed normo-cellular marrow spaces. Granulopoiesis was present with all stages of maturation seen. Megakaryocytes was morphologically unremarkable. Erythropoieisis was preserved. There were a few intranuclear inclusions seen. The intranuclear inclusions were suggestive of Parvovirus infection ( Figure 1). She received intravenous immunoglobulin (IVIg) with 2g/kg in total. Her Hb level was successfully maintained above 10g/dL without further RBC transfusion. WCC and platelet counts also normalized. Her immunosuppression was changed to combination of everolimus, tacrolimus and prednisolone. Parvovirus PCR in June and July 2018 were consequently negative. In October 2018 her Hb level started to drop again. Repeated Parvovirus PCR taken was positive and she was given IVIg again and responded to treatment. She was discharged to her hometown hospital with close monitoring of Parvovirus PCR and Hb level. Figure 1: Intranuclear inclusions in BMAT This case report suggests the importance of including parvovirus B19 infection in the differential diagnosis of persistent anaemia in organ transplant patients and the need to monitor the PCR closely for reactivation and the role of IVIg with reduced IS as part of the management.