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Improvement of Anemia Induced by Parvovirus B19 in a Patient With AIDS After Combined Antiretroviral Therapy

      To the Editor: Persistent parvovirus infection has been reported as a cause of intractable anemia in patients with the acquired immunodeficiency syndrome (AIDS). In anemic patients, treatment with immunoglobulin G (IgG) is typically recommended.
      • Koduri PR
      • Kumapiey R
      • Valladares J
      • Teter C
      Chronic pure red cell aplasia caused by parvovirus B19 in AIDS: use of intravenous immunogiubulin: a report of eight patients.
      Recently, Mylonakis and coworkers
      • Mylonakis E
      • Dickinson BP
      • Milan MD
      • et al.
      Persistent parvovirus B19 related anemia of seven years' duration in an HIV-infected patient: complete remission associated with highly active antiretroviral therapy.
      reported complete remission of red blood cell aplasia induced by parvovirus B19 in a patient with AIDS who received highly active antiretroviral therapy (HAART). In the accompanying case report, we describe a similar result.

      Report of a Case

      In January 1998, a 28-year-old woman with human immunodeficiency virus (HIV-1) infection and anemia was referred to our hospital. Her disease had started in February 1997, presenting as purpura. She was later diagnosed as having HIV-1 infection. Her laboratory test results are listed in Table 1. She was treated with red blood cell and platelet transfusion. Treatment with zidovudine and didanosine and prophylaxis with trimethoprim-sulfamethoxazole were begun. Throughout the evolution of her disease, the plasma concentrations of iron, transferrin, erythropoietin, and lactate dehydrogenase were normal. The reticulocyte count ranged from 0.2% to 1.0%. She was treated with cyanocobalamin, folic acid, and iron supplementation. Soon after, the platelet count increased but the hematocrit did not, which necessitated transfusion of about 3 U of packed red blood cells monthly. Treatment with zidovudine was discontinued, and the patient was only given didanosine.
      Table 1Laboratory Values
      TestFebruary 1997January 1998July 1998March 1999
      Hematocrit (%)27243837
      White blood cell count (x 107L)2.32.37.4
      Platelet count (x 10%)13127130
      Viral load (copies/mL)
      Amplicore.
      25,0003553Undetectable (<400)
      CD4+ cell count (x 10%)0.18
      lmmunofluorescence.
      0.06
      lmmunofluorescence.
      Flow cytometry.
      0.23
      lmmunofluorescence.
      Flow cytometry.
      Reticulocyte count (%)0.9
      * Amplicore.
      lmmunofluorescence.
      Flow cytometry.
      When she came to our hospital in January 1998, a bone marrow aspiration revealed a myeloid:erythroid ratio of 2.2:1. Giant pronormoblasts with clumped basophilic chromatin and cytoplasmatic vacuoles were identified. Bone marrow examination and culture for bacteria and fungi were negative. Serology test results for parvovirus B19 showed an immunoglobulin M (IgM) titer of 1:512 and negative for IgG. A transfusion of 2 U of packed red blood cells was done, and treatment with lamivudine, stavudine, and indinavir was begun.
      The patient's condition improved and required no further transfusions. In July 1998 her serology test result for parvovirus B19 was negative for IgM with an IgG titer of 1:32 last We last saw her in March 1999; she appeared in good general health, and her hematocrit was 38%.

      Comment

      It has recently been reported that HAART causes improvement in some coexisting conditions associated with HIV infection. These include diarrhea caused by microsporidia and Cryptosporidium, Kaposi sarcoma, progressive multifocal cytomegalovirus retinitis, and hepatitis B infection.
      • Scpkowitz KA
      Effect of HAART on natural history of AIDS-related opportunistic disorders.
      • Murphy M
      • Armstrong D
      • Scpkowitz KA
      • Ahkami RN
      • Myskowski PL
      Regression of AIDS-relatcd Kaposi's sarcoma following treatment with an HIV-I protease inhibitor (letter].
      • Aboulafia DM
      Regression of acquired immunodeficiency syndrome-related pulmonary Kaposi's sarcoma after highly active antiretroviral therapy.
      The principal defensive mechanisms against those diseases are cell mediated. Host defense against parvovirus B19 is almost completely mediated by antibodies. Patients with AIDS cannot clear parvovirus B19, which could be explained by a basic defect in the antigen presentation by macrophages or by a defect in the helper function of the CD4+ cell. The repertory of lymphocytes capable of responding to viral epitopes critical for neutralization is limited.
      • Fnckhofen N
      • Abkowitz JL
      • Safford M
      • et al.
      Persistent B19 parvoviras infection in patients infected with human immunodeficiency virus type I (H1V-1): a treatable cause of anemia in AIDS.
      Doubtless the number (and probably the quality) of CD4+ cells is vital in the defense against parvovirus B19. In AIDS patients with red blood cell aplasia treated with IgG, CD4+ cell count was a predictor of disease evolution.
      • Koduri PR
      • Kumapiey R
      • Valladares J
      • Teter C
      Chronic pure red cell aplasia caused by parvovirus B19 in AIDS: use of intravenous immunogiubulin: a report of eight patients.
      • Fnckhofen N
      • Abkowitz JL
      • Safford M
      • et al.
      Persistent B19 parvoviras infection in patients infected with human immunodeficiency virus type I (H1V-1): a treatable cause of anemia in AIDS.
      It is possible that the CD4+ cell count increase induced by HAART improves the capacity of response against parvovirus B19.
      This case is similar to the one communicated by Mylonakis et al.
      • Mylonakis E
      • Dickinson BP
      • Milan MD
      • et al.
      Persistent parvovirus B19 related anemia of seven years' duration in an HIV-infected patient: complete remission associated with highly active antiretroviral therapy.
      HAART might become a new therapeutic approach to anemia induced by parvovirus B19 in patients with AIDS.

      Uncited References

        • Koduri PR
        • Kumapiey R
        • Valladares J
        • Teter C
        Chronic pure red cell aplasia caused by parvovirus B19 in AIDS: use of intravenous immunogiubulin: a report of eight patients.
        Am J Hemalol. 1999; 61: 16-20
        • Mylonakis E
        • Dickinson BP
        • Milan MD
        • et al.
        Persistent parvovirus B19 related anemia of seven years' duration in an HIV-infected patient: complete remission associated with highly active antiretroviral therapy.
        Am J Hemalol. 1999; 60: 164-166
        • Scpkowitz KA
        Effect of HAART on natural history of AIDS-related opportunistic disorders.
        Lancet. 1998; 351: 228-230
        • Murphy M
        • Armstrong D
        • Scpkowitz KA
        • Ahkami RN
        • Myskowski PL
        Regression of AIDS-relatcd Kaposi's sarcoma following treatment with an HIV-I protease inhibitor (letter].
        AIDS. 1997; 11: 261-262
        • Aboulafia DM
        Regression of acquired immunodeficiency syndrome-related pulmonary Kaposi's sarcoma after highly active antiretroviral therapy.
        Mayo Clin Proc. 1998; 73: 439-443
        • Fnckhofen N
        • Abkowitz JL
        • Safford M
        • et al.
        Persistent B19 parvoviras infection in patients infected with human immunodeficiency virus type I (H1V-1): a treatable cause of anemia in AIDS.
        Ami intern Med. 1990; 113: 926-933