Anterior bilateral uveitis and acute parvovirus B19 infection

Parvoviruses are single-stranded DNA viruses, the only one of which known to affect humans is B19. Parvovirus B19 is a ubiquitous micro-organism that causes common infections of respiratory transmission. The prevalence of the virus in the general adult population ranges from 50% to 80%.¹

The course of the infection usually features two phases: a viraemia phase, in which the patient presents flu-like signs and symptoms with malaise, myalgia, fever, headache and chills; and a second phase, characterised by the onset of dermatosis, vasculitis, joint diseases and other general symptoms.² In healthy subjects, the infection may go unnoticed or be concomitant with infectious erythema or joint diseases. In adults, skin lesions are usually absent and joint impairment is most notable, with a particular propensity for the cervical spinal vertebrae, shoulders, elbows, wrists, ankles and feet.³

The infection can be diagnosed in the early phase with the demonstration of IgM antibodies against the virus, and in the disease resolution period by seroconversion to specific IgG antibodies. Treatment of this infection is symptomatic and based on analgesics and anti-inflammatory agents.

We report the case of a 46-year-old male who visited the emergency department due to headache radiating towards the cervical area with night sweats and measurable fever. The patient had also been suffering from back pain and joint pain in the knees and ankles for several weeks. He had already sought treatment for these symptoms and been diagnosed with influenza. Laboratory testing in the emergency department showed C-reactive protein (CRP) 1.6 mg/dl and leukocytosis 12,400/mm.³ A lumbar puncture ruled out meningitis.

As the patient presented significant bilateral conjunctival hyperaemia, he was assessed by Ophthalmology. The ophthalmological examination showed bilateral Tyndall++ with visual acuity of the unit, and examination of the eye fundus revealed no signs of vitritis or retinitis. The patient was diagnosed with bilateral anterior uveitis.

A decision was made to admit him to the internal medicinal department to continue evaluating his systemic condition. He underwent an echocardiogram which, along with negative blood cultures, ruled out endocarditis. Urine sediment and urine culture were also normal. No influenza virus or respiratory syncytial virus (RSV) was detected in the patient’s pharyngeal exudate, and a Mantoux test was negative. A chest X-ray showed no pleural effusion, and the patient’s knees and shoulders showed no abnormalities. Serologies were all negative (Brucella spp., Toxoplasma, syphilis, hepatitis B and C, human immunodeficiency virus [HIV], Coxiella spp., Borrelia spp. and Rickettsia spp.) with IgG positivity for herpes simplex virus, Epstein–Barr virus and IgG and IgM antibodies for parvovirus. Autoimmunity was also negative (antinuclear antibodies [ANAs], antimitochondrial antibodies [AMAs] and extractable nuclear antibodies [ENAs]). Ultimately, the patient’s diagnosis was probable acute infection due to parvovirus B19 and bilateral anterior uveitis.

It is estimated that only 20% of cases of anterior uveitis are of infectious origin; they are largely caused by viruses belonging to the family Herpesviridae.⁴ However, there are few reported cases of infection with parvovirus B19 and uveitis. The four previously published cases (Table 1) were patients under 18 years of age; this case was the first one in an adult.^5–8 There are two theories with regard to ocular involvement in parvovirus B19 infection: one is direct invasion by the virus; the other is induction of autoimmunity.⁸ In our case, no autoantibodies were detected, hence we presumed direct invasion by the virus to be the cause of the uveitis. Furthermore, our patient did not present the typical infectious erythema either. He was treated symptomatically with paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs); his systemic signs and symptoms improved. His bilateral anterior uveitis responded to topical corticosteroid treatment with no associated complications and good subsequent management.

Table 1.

Published cases of uveitis associated with parvovirus B19 infection.

Patient	Age (years)	Sex	Erythema	Autoantibodies	Treatment for uveitis	Reference
1	18	Female	Yes	Unknown	Topical corticosteroid	5
2	6	Female	No	Rheumatoid factor	Topical corticosteroid	6
3	5	Female	Yes	ANAs	Topical corticosteroid	7
4	9	Male	Yes	Negative	Topical corticosteroid	8
5	46	Male	No	Negative	Topical corticosteroid	Case reported

We report the only case of anterior bilateral uveitis associated with probable acute parvovirus B19 infection in an adult that has been published to date. Influenza-like signs and symptoms along with joint pain and subsequent development of uveitis with IgM positivity for parvovirus B19 led to the diagnosis. Uveitis should be considered an uncommon complication in the second phase of parvovirus B19 infection. Further similar cases need be reported if we are to understand the pathophysiological mechanisms of eye involvement in cases of infection with this virus.