Hemicorporal paresthesias in a parvovirus infection

Rojo-Alba, Susana; Alvarez-Argüelles, Marta Elena; Melon, Santiago

doi:10.1016/j.medcle.2018.09.022

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It has a worldwide distribution, and may appear in localized outbreaks. Primo-infection occurs mostly in childhood, and seroprevalence increases with age, reaching 50–80% in adults.Neurological complication of parvovirus infection remains both incompletely described and poorly understood. In a recent review, the most common manifestation observed was found to be encephalitis, followed by encephalopathy and meningoencephalitis. There are also cases of peripheral nervous system involvement such as paresthesia, dysesthesia, cranial nerve palsy, and optic and motor neuropathies, though the results of various imaging techniques and cerebrospinal fluid (CSF) analysis may in fact be normal in such cases. Neurological symptoms are found in both immunocompetent and immunocompromised patients, and the typical defining clinical manifestations of parvovirus infection, if present, (exanthema and arthralgia) may occur either before, alongside or after the neurological manifestation.<a class="elsevierStyleCrossRefs" href="#bib0030">1,2</a>Although its prevalence in neurological pathology is unknown, parvovirus B19 DNA has been found in the CSF of 4.3% of patients with encephalitis.<a class="elsevierStyleCrossRefs" href="#bib0040">3,4</a> This percentage would seem to be high enough to consider testing in such patients where no other clinical cause is found, especially if non-typical encephalitis symptoms are present.We presented a case of a 30-year-old woman with no known underlying disease, nor recent travel abroad, presented to the emergency department for right hemicorporal paresthesia and frontal headache, along with blisters on her fingertips and redness of the palm and back of her hand and her forearm up to the elbow. Previous days she had been experiencing high fever (38.9°C), diarrhea, seizures and had a rash on left arm, chest and both feet. At the time of the physical examination in the emergency department neurological exploration found no clear explanation for the right hemicorporal hypoaesthesia, and brain computed tomography and brain magnetic resonance were normal. Blood laboratory findings were almost normal though she had slight eosinophilia. CSF examination showed no red or white cell count and 53mg/dl glucose and 29mg/dl proteins. The patient was clinically stable and she was discharged home, but CSF samples were taken for microbiological tests.CSF bacteriology tests were all negative. So, following the protocol of the Virology Unit, genomic quantification techniques were performed, which consisted of four “in-house” multiple real time PCRs with MGB probes for detection of various neurotropic viruses: Citomegalovirus (CMV)/Epstein Barr (EBV); Herpes Simplex Virus 1 (HSV-1)/Herpes Simplex Virus 2 (HSV-2)/Varicella Zoster Virus (VZV); Enterovirus (ETV)/Adenovirus (ADV); and Human Herpes Virus 6 (HHV-6)/Human Herpes Virus 7 (HHV-7), which included parvovirus.In CSF 1.2×109copies/ml (9.8 log) of parvovirus VP1 gene was detected, and so peripheral blood and serum samples for biochemical test were then re-examined to confirm this result. Parvovirus DNA was also detected in peripheral blood at levels of 7.6×107copies/ml (7.8 log). In serum, anti-B19 IgM (>48.0U/ml) and IgG (4.4U/ml) were detected by indirect chemiluminescence immunoassay (LIAISON® Biotrin Parvovirus B19 IgM and IgG, Diasorin).As a result of the microbiological findings and neurological manifestation, the patient was hospitalized and started on treatment with 20g iv/24h of immunoglobulin (IVIG) for 5 days. There was an improvement in the hemicorporal paresthesia and rash disappeared during her hospitalization.Two days after patient discharged, her 7-year-old daughter presented in the pediatric emergency department with double slap pruritic exanthema and generalized papulosus maculum exanthema, without any other clinical symptoms. Due to the maternal medical history, pharyngeal swabs were taken and sent for virological testing, and 369copies/103cells (2.6 log) of parvovirus DNA was detected. The child was discharged from the emergency department and made good progress at home without further medical attention.Microbiological studies have to be extended as possible as would be necessary, especially in severe clinical status. This case demonstrates that Parvovirus can cause neurological alterations like it has been reported previously<a class="elsevierStyleCrossRefs" href="#bib0040">3,5</a> and clinicians should have included its detection if conventional pathogens are not present. The correct management of patients (treatment with IVIG or IVG plus steroids) leads to improved prognosis and may avoid both transmission and complications.Conflict of interestsThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interests" ] 1 => array:2 [ "identificador" => "xack450325" "titulo" => "Acknowledgments" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Neurological aspects of human parvovirus B19 infection: a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "F. Barah" 1 => "S. Whiteside" 2 => "S. Batista" 3 => "J. Morris" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/rmv.1782" "Revista" => array:6 [ "tituloSerie" => "Rev Med Virol" "fecha" => "2014" "volumen" => "24" "paginaInicial" => "154" "paginaFinal" => "168" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24459081" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Meningoencephalitis with persistent parvovirus B19 infection in an apparently healthy woman" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "F. Bonvicini" 1 => "G. Marinacci" 2 => "M.C. Pajno" 3 => "G. Gallinella" 4 => "M. Musiani" 5 => "M. Zerbini" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1086/589863" "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2008" "volumen" => "47" "paginaInicial" => "385" "paginaFinal" => "387" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18558883" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Association of human parvovirus B19 infection with acute meningoencephalitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "F. Barah" 1 => "P.J. Vallely" 2 => "M.L. Chiswick" 3 => "G.M. Cleator" 4 => "J.R. Kerr" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0140-6736(01)05905-0" "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "2001" "volumen" => "358" "paginaInicial" => "729" "paginaFinal" => "730" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11551584" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute encephalitis and encephalopathy associated with human parvovirus B19 infection in children" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "T. Watanabe" 1 => "H. Kawashima" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.5409/wjcp.v4.i4.126" "Revista" => array:4 [ "tituloSerie" => "World J Clin Pediatrics" "fecha" => "2015" "volumen" => "4" "paginaInicial" => "126" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A possible parvovirus B19 encephalitis in an immunocompetent adult patient" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Tonnellier" 1 => "J. Bessereau" 2 => "N. Carbonnell" 3 => "B. Guidet" 4 => "J.F. Meritet" 5 => "J.R. Kerr" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jcv.2006.11.004" "Revista" => array:6 [ "tituloSerie" => "J Clin Virol" "fecha" => "2007" "volumen" => "38" "paginaInicial" => "186" "paginaFinal" => "187" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17174596" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack450325" "titulo" => "Acknowledgments" "texto" => "We thank to Ronnie Lendrum for her assistance in English translation." 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Vol. 154. Issue 1.

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