Correspondence

Parvovirus B19

N Engl J Med 2004; 350:2006-2007May 6, 2004

Article

To the Editor:

We would like to add some information to Young and Brown's review (Feb. 5 issue)1 of parvovirus B19 infection and myocarditis. We studied myocardial tissue from five patients with fulminant parvovirus B19–associated myocarditis by in situ hybridization and showed that parvovirus B19 is present exclusively in endothelial cells of the smaller intramyocardial vessels (Figure 1AFigure 1Myocardial Tissue from Patients with Parvovirus B19–Associated Myocarditis.), not in cardiac myocytes.2 Additional immunohistochemical investigation revealed marked expression of E-selectin by endothelial cells of parvovirus B19–infected hearts, a finding indicative of endothelial dysfunction, and massive margination and adhesion of T lymphocytes in the venular compartment (Figure 1B). These processes may lead to disturbances in the coronary microcirculation, followed by an increase in coronary resistance with secondary myofibrillar degeneration (Figure 1B) and myocyte necrosis — lesions that are similar to the morphologic lesions seen in ischemic heart disease.3,4 These findings would explain the observation that many patients with parvovirus B19–associated myocarditis present with the clinical signs that are typical of ischemic heart disease.5

Burkhard D. Bültmann, M.D.
Karl Sotlar, M.D.
Karin Klingel, M.D.
University Hospital Tübingen, 72076 Tübingen, Germany
karin.klingel@med.uni-tuebingen.de

5 References

1. 1

   Young NS, Brown KE. Parvovirus B19. N Engl J Med 2004;350:586-597
   Full Text | Web of Science | Medline

2. 2

   Bultmann B, Klingel K, Sotlar K, et al. Fatal parvovirus B19-associated myocarditis clinically mimicking ischemic heart disease: an endothelial cell-mediated disease. Hum Pathol 2003;34:92-95
   CrossRef | Web of Science | Medline

3. 3

   Baroldi G. Myocardial cell death, including ischemic heart disease and its complications. In: Silver MD, Gotlieb AI, Schoen FJ, eds. Cardiovascular pathology. 3rd ed. New York: Churchill Livingstone, 2001:198-255.
   

4. 4

   Arnold G, Kaiser C, Fischer R. Myofibrillar degeneration -- a common type of myocardial lesion and its selective identification by a modified Luxol Fast Blue stain. Pathol Res Pract 1985;180:405-415
   CrossRef | Web of Science | Medline

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   Kuhl U, Pauschinger M, Bock T, et al. Parvovirus B19 infection mimicking acute myocardial infarction. Circulation 2003;108:945-950
   CrossRef | Web of Science | Medline

To the Editor:

In their review of parvovirus B19, Young and Brown do not mention associations between this virus and renal diseases. They acknowledge an association with Henoch–Schönlein purpura, but recent reports have shown that this virus also has a role in some cases of collapsing focal segmental glomerulosclerosis1 and acute proliferative glomerulonephritis with hypocomplementemia.2 The patients in these cases were otherwise healthy or were renal-transplant recipients. Renal epithelial-cell infections may lead to collapsing focal segmental glomerulosclerosis, whereas parvovirus immune complexes trapped in the subendothelial or mesangial areas of the nephron may lead to proliferative glomerulonephritis. Finally, because of its effects on erythroid progenitors, parvovirus B19 infection should be considered among the possible diagnoses in certain patients with end-stage renal disease who have anemia that does not respond to erythropoietin.3

Paul H. Pronovost, M.D.
Waterbury Hospital, Waterbury, CT 06708
ppronovost@sbcglobal.net

3 References

1. 1

   Moudgil A, Nast CC, Bagga A, et al. Association of parvovirus B19 infection with idiopathic collapsing glomerulopathy. Kidney Int 2001;59:2126-2133
   CrossRef | Web of Science | Medline

2. 2

   Iwafuchi Y, Morita T, Kamimura A, Kunisada K, Ito K, Miyazaki S. Acute endocapillary proliferative glomerulonephritis associated with human parvovirus B19 infection. Clin Nephrol 2002;57:246-250
   Web of Science | Medline

3. 3

   Duranay M, Bali M, Sahin M, Yakinci G, Vurgun N, Dilmen U. Parvovirus B19 infection and unresponsiveness to erythropoietin therapy in haemodialysis patients. Nephrol Dial Transplant 1998;13:779-780
   CrossRef | Web of Science | Medline

Author/Editor Response

Space constraints prevented us from describing in full detail the potential role of parvovirus B19 in diverse syndromes; such discussions can be found elsewhere.1 As we did mention, parvovirus B19 has been implicated in cardiac disease, although most pathological studies, especially of fetal myocarditis, have suggested that there is direct infection of myocardiocytes.2 Perhaps endothelial involvement represents vasculitis.

As for kidney disease, a number of reports have described the detection of parvovirus B19 in renal tissue.3,4 Tanawattanacharoen and colleagues have also implicated parvovirus B19 in focal segmental glomerulosclerosis,5 although they also were able to detect B19 DNA in two of four patients who had undergone nephrectomy for malignant disease. As with heart disease, the role of B19 is unclear, and vascular infection may be an underlying mechanism in both organs.

Neal S. Young, M.D.
Kevin E. Brown, M.D.
National Heart, Lung, and Blood Institute, Bethesda, MD 20892
youngn@nhlbi.nih.gov

5 References

1. 1

   Török TJ. Unusual clinical manifestations reported in patients with parvovirus B19 infection. In: Anderson LJ, Young NS, eds. Human parvovirus B19. Vol. 20 of Monographs in virology. Basel, Switzerland: Karger, 1997:61-92.
   

2. 2

   Porter HJ, Quantrill AM, Fleming KA. B19 parvovirus infection of myocardial cells. Lancet 1988;1:535-536
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3. 3

   Mori Y, Yamashita H, Umeda Y, et al. Association of parvovirus B19 infection with acute glomerulonephritis in healthy adults: case report and review of the literature. Clin Nephrol 2002;57:69-73
   Web of Science | Medline

4. 4

   Wierenga KJ, Pattison JR, Brink N, et al. Glomerulonephritis after human parvovirus infection in homozygous sickle-cell disease. Lancet 1995;346:475-476
   CrossRef | Web of Science | Medline

5. 5

   Tanawattanacharoen S, Falk RJ, Jennette C, Kopp JB. Parvovirus B19 DNA in kidney tissue of patients with focal segmental glomerulosclerosis. Am J Kidney Dis 2000;35:1166-1174
   CrossRef | Web of Science | Medline

Citing Articles (5)

Citing Articles

1. 1

   K. Klingel, R. Kandolf. (2008) Virale Myokarditis im Kindesalter. Rechtsmedizin 18:5, 349-358
   CrossRef

2. 2

   Albert J. Eid, Robert A. Brown, Robin Patel, Raymund R. Razonable. (2006) Parvovirus B19 Infection after Transplantation: A Review of 98 Cases. Clinical Infectious Diseases 43:1, 40-48
   CrossRef

3. 3

   F. Zack, K. Klingel, R. Kandolf, R. Wegener. (2005) Sudden cardiac death in a 5-year-old girl associated with parvovirus B19 infection. Forensic Science International 155:1, 13-17
   CrossRef

4. 4

   Burkhard D. Bültmann, Karin Klingel, Michael Näbauer, Diethelm Wallwiener, Reinhard Kandolf. (2005) High prevalence of viral genomes and inflammation in peripartum cardiomyopathy. American Journal of Obstetrics and Gynecology 193:2, 363-365
   CrossRef

5. 5

   Achim Gutersohn, Ulrich Zimmermann, Thomas Bartel, Raimund Erbel. (2005) A rare case of acute 'infective' myocardial infarction triggered by acute parvovirus B19 myocarditis. Nature Clinical Practice Cardiovascular Medicine 2:3, 167-171
   CrossRef