Case discussion

Dr. V. Rajagembeeran M.D Pediatrics,

Post Doctoral Fellowship in Pediatric Neurology,
SAT Hospital, Trivandrum Govt medical college
Case History
Presentation At 11 months:
 11 months old Nivedha female child was
admitted with c/o fever & irritability in our
SAT hospital.
 Child had elevated total count with
normal CSF study.
 A diagnosis of aseptic meningitis was
made and was treated for 8 days. After that
child started losing milestones.
PRESENTATION AT 12 months
At 12 months child was admitted again for
evaluation of global developmental delay.
Investigations done showed:
Hb 7.7 gms%

WBC 23400

Marked Eosinophilic 24%

counts
PS Hypochromic microcytic anemia

Bone Marrow immature lymphocytes with scant

cytoplasm, small rounded nuclei
 MRI was done and it showed hyperintensies in
the deep white matter involving bilateral fronto-
parietal ,internal capsule, external capsule, dorsal
pons, cerebral peduncle, body of corpus callosum
and some areas of sub cortical white matter
suggestive of Leukodystrophy.
 In MRS there is no specific peak.
 Both CSF and serum showed PCR positivity for
Parvo viruses infection.
 Child was treated symptomatically. There was no
improvement in global development delay and
was sent home, advising follow up.
PRESENTATION AT 15 months
Child was again admitted with c/o
Difficulty in vision,
Persistent head turn to left side.
Irritability and incessant crying with regression of
milestones.
No h/o seizures.
O/E: altered sensorium+ , no facial dysmorphism,
intermittent torticolis, pupils reacting to light.
EOM- Normal, no nystagmus.
Opthalmological examination showed optic
atrophy.
Tone Hypotonic
Power 3/5 in all 4 limbs
Reflexes Normal

Hb 8.8 g%
WBC 20,700 Eosinophilia(20%)
Thyroid profile, Normal
ammonia, lactate,pH
This time also child had PCR detected parvo
virus B19 in CSF.
Hence the diagnosis of Persistent Parvovirus
B19 Infection is made.
Treatment course
 Child was treated with Acyclovir, IVIG and Methyl
Prednisolone.
 Child showed improvement in sensorium.
 Incessant cry and irritability decreased.
 Baby was able to recognise mother by voice and
was consolable easily.
 Torticolis decreased. Partial head control
attained.
 Opthalmological examination showed persistence
of optic atrophy. VEP was normal.
 Child was put on follow up then.
Introduction
• The parvoviruses are small, single stranded
DNA viruses.

• The primary target of B19 infection is the

erythroid cell line, specifically erythroid
precursors near the pronormoblast stage.
Clinical manifestations of persistent
parvo virus B19
1. Erythema infectiosum (Fifth disease)
2. Arthropathy
3. Transient Aplastic crisis
4. Fetal hydrops and fetal anemia
5. Myocarditis
6. Papular purpuric glove and stocks syndrome (PPGSS).
7. Rheumatic disease
8. Less commonly recognized , but receiving increasing
attention recently is neurological manifestations.
Neurological manifestation of
persistent parvo virus B19
1.Seizures
2.Meningitis
3.Encephalitis
4.Encephalopathy
5.Neuopathy
6. Neurological Amyotrophy
7.Carpel tunnel syndrome
8.GBS
9.Optic atrophy
10.Transverse myelitis
11.Cerebellar ataxia
Discussion
This is a case report of persistent parvo virus
B19 infection presented with neurological and
hematological manifestations.
Although persistent parvo virus B19 was found
routinely in immunocompromised, sickle cell,
and post transplant patients, recently it is
being noticed in immunocompetent patients
also.
Encephalitis remains the predominant
neurological manifestation of parvo virus
B19.
The MRI findings of our patient showing
hyperintensities in white matter suggestive
of leukodystrophy was rare neurologic
manifestation with parvo virus B19.
The reason for persistence of parvo virus was
being postulated as inappropriate cytokine
activation.
In meningioencephalitis and demylenation by
parvo virus B19 cytokine network may play a
role.
Autonomous parvo viruses can persist in cells
for long periods in the absence of lysis and in
the presence of the requisite helper functions.
 Cytokine Up-regulation
Various reports have documented cytokine
dysregulation during acute B19 infection.
Elevated levels of cytokines are associated with
many neurological disorders including viral
encephalitis and meningitis and a recent report
has shown a raised levels of IL-6, IFN, TNF, GM-
CSF and MCP-1 in serum samples and in the CSF .
In addition, it might be hypothesised that such
cytokine induced alteration may affect the ability
of the virus to enter cells of the CNS.
• There is significant increase in proinflammatory
cytokines elevation of TNFa and IFNg.

• study show increased levels of TNFa, IFNg, IL-6,

MCP-1, and GM-CSF in the serum and CSF of
cases of B19 meningioencephalitis

• data show that those HLA-DRB1 alleles associated

with symptomatic parvovirus B19 infection
• Eosinophilic inclusion bodies has been found
in some of bone marrow transplant patients
having parvo infection.