Cardiac disorders Intrauterine B19 has a particular affinity for the P antigen expressed on fetal cardiac myocytes, which leads to high-output cardiac failure and nonimmune hydrops fetalis.35 This affinity continues into adulthood, and B19 infection and other viruses should be included in the differential of acute myocarditis and dilated cardiomyopathy. In one study of 24 consecutive patients who had normal results on emergent coronary angiography, endomyocardial biopsy specimens revealed virus-positive results in 17 patients (71%). Twelve patients were infected with B19; three patients were infected with enterovirus; and two patients were infected with adenovirus. 40 Another study found B19 in 49 of 87 (56%) endomyocardium biopsies, human herpesvirus 6 (HHV6) in 16 (18%), and combined B19 and HHV6 in 15 (17%).41 Compared with the HHV6-infected patients, the clinical course for those with B19 infection was primarily benign. Most patients experienced significant or complete recovery. Furthermore, B19 did not directly infect the myocytes; rather myocardial damage was secondary to inflammatory cell migration.41 Clinicians should be aware of potential viral etiology in patients presenting with acute MI. Recovery may depend upon the type of virus. Study outcomes differed, ranging from full recovery to progressive LVD clinically diagnosed as dilated cardiomyopathy.40,41
Dermatologic disorders A known adage is that when confronted with an atypical rash, clinicians reflect that it “must be viral.” Time may prove this diagnosis correct more often than not as B19 seems to have an affinity for the skin and atopy may predispose to it. Researchers documented the persistence of the B19 genome in the cutaneous lesions of seven patients with connective tissue diseases, including dermatomyositis, SLE, RA, necrotizing vasculitis, and microscopic polyarteritis nodosa. An absent IgM response despite persistent infection may be the result of a failure to produce neutralizing IgM antibodies caused by a specific immune defect.42 B19 PCR DNA was also significantly elevated in 36 of 48 patients (75%) with systemic sclerosis compared with 53 of 97 (55%) normal controls. The occurrence rate of B19 infection in study patients with SLE, dermatomyositis, morphea, or graftversus- host disease showed no difference from controls.43
Globalization necessitates knowledge of rashes that are rare in the United States but more common in other parts of the world. Although considered more common in Europe and the Middle East, papular-purpuric gloves and socks syndrome (PPGSS)—characterized by fever, acral pruritus, edema, petechiae, and oral erosions—has been seen in the United States. A case report from Yale-New Haven Hospital reported a positive IgM finding in serum drawn on day 9 of an illness in a 20-year-old female patient; 9 months later, the patient tested positive for B19 IgG.44 An interesting case of mother-todaughter transmission of PPGSS found presence of B19 IgM in the mother on day 3 and in the daughter on day 4.45 Three weeks later, both patients were IgM- and IgG-positive. This is the first documented case of mother and daughter presenting together with PPGSS.45 Researchers note that sufficient evidence exists to suggest that PPGSS is a rare but distinctive manifestation of primary B19 infection in young adults.
Hepatic disorders The B19 etiology of unexplained fulminant hepatitis was shown when the B19 genome was isolated in 4 of 11 children admitted to a Belgian hospital. The distinguishing points in these children were that there was no jaundice, a low bilirubin level, high ALT or AST activity, and a rapid return to normal function.46 A Japanese study revealed that 4 out of 15 patients (aged 7 months to 5 years) who tested positive for B19 IgM, IgG by PCR had acute hepatitis of unknown origin. In all of the cases, serum concentrations of AST and ALT normalized within 3 weeks. Clinicians should recognize that fulminant hepatitis caused by B19 may have a significantly better prognosis.47
CONCLUSION
B19 infection is a vital addition to the differential diagnosis, whether the patient has a suspected virus-related illness or a condition not classically considered viral in etiology, such as the four cases presented in this article. In addition, questions about more widespread screening of blood products, pregnant women, and even vaccine development exist for clinicians to consider.48 The many faces of B19, as well as other emerging members of the Parvoviridae family, can challenge the best diagnostician.49 Therefore, maintaining an index of suspicion for this tiny virus is good medicine. JAAPA
Ellen Mandel is an associate professor at Seton Hall University, School of Health and Medical Sciences Physician Assistant Program, South Orange, New Jersey. She has indicated no relationships to disclose relating to the content of this article.
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