“Immunosuppression Modulation Facilitates Recovery from Parvovirus B19 Infection in Kidney Transplantation.”

Parvovirus B19 infection has characteristic tropism to infect red blood cell and their precursor, causing erythropoietin resistant anaemia in post-transplant immunocompromised patients. Incidence varies 0-58%.  The median onset of infection post transplantation is 5 week. One fourth of the patients have recurrence after recovery. In paucity of data, immunosuppression reduction with IVIG remains the treatment of choice. We present a post renal transplant patient having severe anaemia due to Parvovirus B19 infection

 A 35-year-old female underwent deceased donor kidney transplant (DDKT) with Anti- thymocyte globulin followed by tacrolimus, mycophenolate mofetil (MMF) and prednisolone. Six weeks post-transplant she had drop in Hb and found to have Parvovirus B19 infection with Blood DNA PCR > 109 copies/ml. She was treated with intravenous immunoglobulin (IVIG) and  blood transfusions. She had persistent disease which was treated with repeat IVIG. Bone marrow examination was done 4 months post-transplant to evaluate other causes of anemia. It was also suggestive of pure red cell aplasia (PRCA) secondary to Parvovirus B19 as evidenced by intranuclear lesions. There was no response even after 4 courses of IVIG, so her immunosuppression was reduced after 1 year of transplant. Initially MMF was changed to Everolimus and then Everolimus also stopped after 6 months as anaemia persisted. Hydroxyurea was tried for a month but discontinued as it led to severe cytopenia. She had been transfused with 39 units Leucocyte depleted Packed red blood cell transfusion (LD-PRBCs) over 2 years at which point, tacrolimus was changed to cyclosporine. Two weeks later, her Hb began to rise and repeat Parvovirus B19 DNA PCR was negative. It increased to the extent that she is now requiring phlebotomies, probably secondary to Post transplant erythrocytosis which was initially overshadowed by PRCA. Though her Parvo PCR stays around  103  she is completely asymptomatic. To maintain her Hb intermittent phlebotomies are required. 

Discussion- The first case of PRCA after kidney transplantation was reported by Suzuki et al. in 1996 where in PV B19 PCR was not tested, bone marrow was s/o PRCA, anaemia improved after conversion of Tacrolimus to Cyclosporine and the title of this report was ‘PURE RED CELL APLASIA INDUCED BY FK506. While there are case series suggesting decreasing Immunosuppression and successful treatment after stopping MMF. In some cases however, withdrawal of MMF alone did not affect the course of the disease as in ours. Since Hydroxyurea (HU) is an inhibitor of DNA synthesis thus it Is used in treating parvovirus B19 and thus was tried in our case. Tacrolimus can cause Pure Red Cell Aplasia (PRCA) by potentially impairing the bone marrow's ability to produce red blood cells, possibly through increased TGF-β1 production or by hindering the body's ability to clear parvovirus B19 infection.

Conclusion – In a patient with Post transplant anaemia, parvovirus B 19 should be considered as a D/D. Immunomodulation- Withholding antiproliferative, giving Immunoglobulins can help. Conversion of tacrolimus to cyclosporine is a viable option.