Chronic hepatitis caused by persistent parvovirus B19 infection

Abstract

Background: Human infection with parvovirus B19 may lead to a diverse spectrum of clinical manifestations, including benign erythema infectiosum in children, transient aplastic crisis in patients with haemolytic anaemia, and congenital hydrops foetalis. These different diseases represent direct consequences of the ability of parvovirus B19 to target the erythroid cell lineage. However, accumulating evidence suggests that this virus can also infect other cell types resulting in diverse clinical manifestations, of which the pathogenesis remains to be fully elucidated. This has prompted important questions regarding the tropism of the virus and its possible involvement in a broad range of infectious and autoimmune medical conditions.

Case presentation: Here, we present an unusual case of persistent parvovirus B19 infection as a cause of chronic hepatitis. This patient had persistent parvovirus B19 viraemia over a period of more than four years and displayed signs of chronic hepatitis evidenced by fluctuating elevated levels of ALAT and a liver biopsy demonstrating chronic hepatitis. Other known causes of hepatitis and liver damage were excluded. In addition, the patient was evaluated for immunodeficiency, since she had lymphopenia both prior to and following clearance of parvovirus B19 infection.

Conclusions: In this case report, we describe the current knowledge on the natural history and pathogenesis of parvovirus B19 infection, and discuss the existing evidence of parvovirus B19 as a cause of acute and chronic hepatitis. We suggest that parvovirus B19 was the direct cause of this patient's chronic hepatitis, and that she had an idiopathic lymphopenia, which may have predisposed her to persistent infection, rather than bone marrow depression secondary to infection. In addition, we propose that her liver involvement may have represented a viral reservoir. Finally, we suggest that clinicians should be aware of parvovirus B19 as an unusual aetiology of chronic hepatitis, when other causes have been ruled out.

Figure 1

Time course of hepatic enzymes and haematological, immunological, and virological parameters. Values are shown as percentages of reference values over time (t = 0: time of initial symptoms). Reference values were chosen as the lowest of the normal range, with the exception of ALAT, for which the highest normal range value was used. Time points for intravenous immunoglobulin (IVIG), prednisolone treatment, liver biopsy, and parvovirus B19 DNA status are indicated.

Figure 2

Liver biopsy with chronic hepatitis. An expanded portal tract shows chronic inflammation with a modest degree of active interface hepatitis. On the upper right hand side of the figure is an area of bridging septal fibrosis. (Haematoxylin and eosin staining).