Persistent Anemia in a Renal Transplant Recipient

Abstract

Diagnosis: Chronic persistent parvovirus B19 infection. The bone marrow biopsy demonstrated markedly hypocellular marrow (10% cellularity) (figure 1) with incomplete erythroid maturation and increased storage of iron. Hematoxylin and eosin staining of the bone marrow specimen revealed occasional enlarged cells with prominent nuclear inclusions (giant pronormoblasts), which are characteristic of parvovirus B19 infection (figure 2). In contrast, cells infected with cytomegalovirus (CMV) usually have both cytoplasmic and intranuclear inclusions, which give the cells the characteristic owl eye appearance. The results of PCR of the bone marrow specimen for Epstein-Barr virus and CMV DNA were negative, and the findings of chromosomal analysis of bone marrow were also normal. The result of PCR of the bone marrow specimen for parvovirus B19 DNA was positive. The patient was treated with a 5-day regimen of intravenous immunoglobulin and has not required blood transfusions since the completion of treatment. His hematocrit rose quickly to 36%-37.9 % by 2 weeks after treatment and to 42.2% by 1 month after treatment. Parvovirus B19 is a nonenveloped, single-stranded DNA virus that commonly causes a benign childhood infection, fifth disease (erythema infectiosum), which typically manifests as a Figure 2. High-pow r micrograph (hematoxylin and eosin stain; original magnification, x100) of a bone marrow sp cimen showing giant pronormoblast (arrow) with prominent nuclear inclusions.