Disseminated Human Parvovirus B19 Infection Induced Multiple Organ Dysfunction Syndrome in an Adult Patient With Alcoholic Hepatitis Complicated by Hemolytic Anemia: A Case Report and Literature Review

Abstract

Background: Human parvovirus B19 (B19) can cause acute hepatitis and is attributed to the high mortality of alcoholic hepatitis (AH). B19 infection is generally self-healing in previously healthy people, but it can cause fatal effects in some high-risk groups and increase its virulence and infectivity. Disseminated B19 infection-induced multiple organ dysfunction syndrome (MODS) in patients with AH has not been reported yet. Here, we described B19 viremia in an adult patient with AH accompanied by hemolytic anemia (HA), leading to disseminated infection and secondary MODS, as well as self-limiting B19 infections in seven nurses caring for him. Meanwhile, we reviewed the literature on AH and B19 infection.

Case presentation: A 43-year-old male patient with AH accompanied by HA was transferred to the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China, on March 31, 2021. After supportive treatment, his transaminase and bilirubin levels were reduced, but his anemia worsened. He received a red blood cell (RBC) infusion on April 9 for hemoglobin (Hb) lower than 6 g/dl. On April 13, he suddenly had a high fever. Under empirical anti-infection, his high fever dropped and maintained at a low fever level; however, his anemia worsened. On April 25, he was transferred to the medical intensive care unit (MICU) due to severe pneumonia, acute respiratory distress syndrome (ARDS), acute aplastic crisis (AAC), and hemophagocytic syndrome (HPS), which were subsequently confirmed to be related to B19 infection. After methylprednisolone, intravenous immunoglobulin (IVIG), empirical anti-infection, and supportive treatment, the lung infection improved, but hematopoietic and liver abnormalities aggravated, and systemic B19 infection occurred. Finally, the patient developed a refractory arrhythmia, heart failure, and shock and was referred to a local hospital by his family on May 8, 2021. Unfortunately, he died the next day. Fourteen days after he was transferred to MICU, seven nurses caring for him in his first two days in the MICU developed self-limiting erythema infectiosum (EI).

Conclusions: B19 infection is self-limiting in healthy people, with low virulence and infectivity; however, in AH patients with HA, it can lead to fatal consequences and high contagion.

Keywords: acute aplastic crisis; alcoholic hepatitis; erythema infectiosum; hemolytic anemia; hemophagocytic syndrome; human parvovirus B19; multiple organ dysfunction syndrome.

Figure 1

(A) Chest CT examination at admission showed no obvious abnormalities. (B) Chest CT showed a few scattered vague exudates and small nodules at midnight on the 26th day of admission before the patient was transferred to the medical intensive care unit (MICU). (Ca) Bedside chest radiograph showed consolidations, bilateral involvement, peripheral distribution, lower zone dominance, and reduction in lung volume on the third day in MICU. (Cb) Bedside chest radiograph showed lung lesions were significantly improved on the eighth day in MICU. (D) Abdominal color Doppler ultrasound reported fatty liver, alcoholic liver disease, dilated portal vein, and hepatosplenomegaly and ascites at admission.

Figure 2

(Aa) Blue–purple ecchymosis on the proximal right upper limb of the patient when being transferred to medical intensive care unit (MICU). (Ab) Blue–purple ecchymosis did not appear on his trunk, lower limbs, and upper left limb at that time. (Ba) Strained blisters filled with serous fluids on predominantly erythematous skin on his torso (Ba; buttocks as a representative) and limbs [(Bb); left limb as a representative] on the tenth day in MICU. (Ca) Bone marrow examination on the fourth day of admission (smear; ×400) revealed active bone marrow hyperplasia; a significant increase of red blood cells (RBCs) (52.25%) of which the middle and late stages of RBC account for a large proportion; no obvious abnormalities of granulocytes; lymph proportion was reduced with the morphology roughly normal; platelets were significantly reduced and distributed in single or clusters, with no clue to acute aplastic crisis or hemophagocytic syndrome. (Cb) Bone marrow examination on the second day in MICU (smear; ×400) revealed a marked decrease in the density of erythroblasts, inhibition of megakaryocyte maturation, and easily seen phagocytes containing vacuoles, platelets, impurities, and other components (black arrow).

Figure 3

(A) The distribution of the main clinical events and body temperature of the patient on the time axis. (B–E) The Ret count, Hb, WBC, and TBIL values of the patient on the time axis. P1, day 1 pre-hospital; P2, day 2 pre-hospital; D1 to D39, day 1 to day 39 of hospital admission; AH, alcoholic hepatitis; HA, hemolytic anemia; ARDS, acute respiratory distress syndrome; HPS, hemophagocytic syndrome; AAC, acute aplastic crisis; Ret, reticulocytes; Hb, hemoglobin; WBC, white blood cell; TBIL, total bilirubin.

Figure 4

(A) Next-generation sequencing (NGS) results of blood collected at 8 h after the patient was transferred to the medical intensive care unit (MICU) reported extremely high DNA copies of B19 (1,605,726 copies/µg DNA, and the relative abundance was 99.99%). (B) NGS results of bronchoalveolar lavage fluid (BALF) collected on the third day in MICU reported high DNA copies of B19 (15,938 copies/µg DNA, and the relative abundance was 97.85%). (C–F) Real-time PCR confirmed positive results of B19 in bone marrow, gastric juice, BALF, and urine collected on the eighth day in MICU. (G–J) Real-time PCR confirmed positive results of B19 in skin blister fluid, sputum, and blood collected on the eighth day in MICU. (J) Real-time PCR showed that the previously positive result of B19 in urine became negative in the urine sample collected on the tenth day in MICU.