ParvovirusSatoko Ugai, MD, a Yuta Aizawa, MD, PhD,B19: b Tetsuya Kanayama, A Cause MD, a Akihiko Saitoh, of MD, PhDb Sepsislike Syndrome in anabstract Infant Parvovirus B19 (PB19) is an important human pathogen that results in a wide spectrum of clinical outcomes, from mild, self-limiting erythema infectiosum in immunocompetent children and arthralgia in adults to lethal cytopenia in immunocompromised patients and intrauterine – fetal death.‍ However, there have been few reports of PB19 infection in neonates or young infants (aged 28 90 days), and no previous reports contained descriptions of PB19 infection as a cause of sepsislike syndrome in this age group.‍ We report a case of sepsislike syndrome caused by PB19 infection in a 56-day-old infant whose mother had polyarthralgia at the time of his admission.‍ PB19 infection was diagnosed on the basis aDepartment of Pediatrics, Tokamachi Prefectural Hospital, of positive polymerase chain reaction results for PB19 DNA in the Tokamachi, Niigata, Japan; and bDepartment of Pediatrics, serum and cerebrospinal fluid.‍ Positive immunoglobulin M and negative Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan immunoglobulin G for PB19 suggested acute infection.‍ He was admitted to the ICU because of poor peripheral circulation, but fully recovered without Dr Ugai conceived and designed the study and antibiotic administration.‍ After excluding other possible pathogens, PB19 drafted the initial manuscript; Drs Aizawa and Kanayama critically reviewed the manuscript; should be suspected as a cause of sepsislike syndrome in young infants, Dr Saitoh supervised the study and revised and especially those who have close contact with PB19-infected individuals.‍ critically reviewed the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. Parvovirus B19 (PB19) infection young infants.‍ Herein, we report a case DOI: https:// doi. org/ 10. 1542/ peds. 2017- 1435 is common in childhood, but of sepsislike syndrome caused by PB19 Accepted for publication Feb 21, 2018 its clinical manifestations vary infection in a young infant.‍ Address correspondence to Satoko Ugai, MD, considerably in relation to patient CASE PRESENTATION Department of Pediatrics, Tokamachi Prefectural 1, 2 Hospital, Takayama, Tokamachi, Niigata 948-0055, age and immunologic status.‍ Japan. E-mail: [email protected] PB19 infection typically presents as erythema infectiosum in healthy, A term 56-day-old boy with a birth PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). immunocompetent school-aged weight of 3072 g was admitted to our children.‍ Arthralgia is the most hospital in January 2016 because of Copyright © 2018 by the American Academy of Pediatrics common manifestation in adults, high fever and poor sucking.‍ Perinatal particularly in women.‍ PB19 can cause history was unremarkable.‍ He had FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships fetal hydrops when mothers3 develop close contact with sick family members relevant to this article to disclose. intrauterine infections.‍ Less common who had clinical symptoms of PB19 FUNDING: Supported by a grant from the National manifestations of PB19 infection in infections, namely a 12-year-old cousin – Center for Child Health and Development, Japan neonates and young infants (aged and 8-year-old cousin with erythema 4 ’ (24-11) to Dr Saitoh. 28 90 days)5 include meningitis, 6 infectiosum 10 and 6 days before POTENTIAL CONFLICT OF INTEREST: The authors hepatitis, leukoerythroblastosis,7 our patient s admission, respectively.‍ have indicated they have no potential conflicts of interest to disclose. transient myeloproliferation,8 In addition, his mother reported encephalitis, and hemophagocytic9 systemic joint pain, a sign of PB19 lymphohistiocytosis.‍ However, PB19 infection, on the day of his admission.‍ To cite: Ugai S, Aizawa Y, Kanayama T, et al. infection in this population is rare, and However, they were not tested for Parvovirus B19: A Cause of Sepsislike Syndrome no researchers of previous reports PB19-specific antibodies or viral in an Infant. Pediatrics. 2018;141(6):e20171435 described PB19 infection as a cause DNA by immunoassay or quantitative of sepsislike syndrome in neonates or polymerase chain reaction (PCR) assay.‍ Downloaded from www.aappublications.org/news by guest on October 1, 2021 PEDIATRICS Volume 141, number 6, June 2018:e20171435 CASE REPORT DISCUSSION In the emergency department, parechoviruses, and adenovirus, but ° – his vital signs were as follows: all tests yielded negative results.‍ This is the first case report of a body temperature, 39.‍0 C; pulse young infant (aged 28 90 days) rate, 210 beats per minute; blood As stated above, the boy had close with a sepsislike illness caused by pressure, 95/45 mmHg; and contact with family members with PB19.‍ This age group is susceptible respiratory rate, 45 breaths per erythema infectiosum.‍ His mother to numerous pathogens; thus, when minute.‍ Peripheral oxygen saturation developed rash on her extremities bacterial infection is ruled out, viral was 97% in room air.‍ Physical a few days after she developed etiologies should be considered, examination revealed significant arthritis.‍ Because we suspected an including herpes simplex– virus, abdominal distension.‍ Capillary outbreak of PB19 among his family enterovirus, human12 14 parechoviruses, refilling time was prolonged members, PB19 was considered as a and adenovirus.‍ We diagnosed (up to 5 seconds), and his possible cause of his condition.‍ PB19 PB19 infection after real-time PCR extremities were cold.‍ He had DNA was detected in serum and CSF detection of PB19 in serum and no bulging anterior fontanelle, on admission, when he presented CSF samples and exclusion of other rash, petechiae, vesicular lesions, with symptoms of sepsislike × possible pathogens.‍ hepatosplenomegaly, or abnormal syndrome, and viral load was high on × × 10 PB19 DNA viral load in serum was neurologic signs.‍ real-time PCR (1.‍6 10 copies/mL 10 × 7 extremely high (>1.‍0 10 copies/mL) Laboratory findings on admission in serum and 1.‍6 10 copies/mL – × 10 in our patient.‍ Researchers of a in CSF).‍ Sequence analysis of the were9 a white blood cell count of 3.‍1 previous study reported that PB19 × 10 /L (normal range: 6.‍0 14.‍0 NS1-VP1 overlapping region (from DNA viral load in the serum was high 9 – × –6 × 10 /L), hemoglobin of 97 g/L nt 1765 to nt 112672) of PB19 showed (median: 7.‍63 103 genomes/mL;6 (normal range: 98 116 g/L), mean genotype 1A.‍ The presence of – range: 4.‍48 10 8.‍31 10 ) corpuscular volume of 88 fL (normal positive immunoglobulin M (IgM) – among patients10 with acute erythema range: 72 88 fL), reticulocyte count results and negative immunoglobulin × infectiosum.‍ The researchers of of 3.‍0% (normal range: 0.‍1% 2.‍9%), G (IgG) results indicated acute – × that report also found that PB19 DNA and9 a platelet count of 218 infection.‍ Ultimately, sepsislike viral load in serum during the acute 10 /L (normal range: 84 478 syndrome due to PB19 infection phase of aplastic crisis in chronic 9 × – × 10 /L).‍ A blood smear revealed no was diagnosed.‍ hemolytic anemia was10 extremely13 evidence of atypical lymphocytes or high (range: 1.‍0 10 1.‍0 10 ).‍ abnormal red blood cell morphology.‍ During hospitalization, fever The extremely high viral load in Biochemistry testing revealed an – persisted for 2 days but resolved our patient suggests that PB19 aspartate aminotransferase level of with supportive care.‍ He was well infection was the cause of severe 57 U/L (normal range: 22 63 U/L), – enough to be transferred from sepsislike syndrome.‍ The patient an alanine aminotransferase level of the ICU to the pediatric ward on had leukopenia at admission, which 38 U/L (normal range: 12 45 U/L), – hospital day 2 and was discharged suggests the possibility of viral lactate dehydrogenase of 237 U/L from the hospital on day 6 without infection, including PB19 infection, as × (normal range: 170 580 U/L), total sequelae.‍ At the time of discharge, a cause.‍ However, leukopenia was not – × 9 bilirubin level of 0.‍94 mg/dL (normal white blood cell count (13.‍2 10 /L; reported by researchers in previous 9 – – range: <1.‍0 mg/dL), and a C-reactive × – normal range: 6.‍0 14.‍0 109/L) case studies of young infants (aged4 7, 9 protein level of 21.‍9 nmol/L (normal – × and platelet count (532 109 /L; 28 90 days) with PB19 infection.‍ range: 7.‍6 150.‍5 nmol/L).‍ No normal range: 84 478 10 /L) had Therefore, it is uncertain whether – abnormal findings were observed in improved, and hemoglobin level leukopenia is a characteristic of PB19 cerebrospinal fluid (CSF) or urine.‍ (90 g/L, normal range: 98 116 g/L) infection in young infants.‍ The patient did not present with was close to normal range.‍ No The prevalence of antibodies against additional measurement of viral any obvious source of fever on PB19 in pregnant women was 15 admission.‍ He was critically ill with load was performed during his reported to be 55.‍4% in Japan, – poor circulation and was admitted hospitalization.‍ Findings of a 2-month which is similar to prevalences to an ICU.‍ Bacterial infection was follow-up examination were all normal.‍ reported in other countries (30% excluded on the basis of negative 50%), including the Netherlands,16 results for blood, urine, and Written informed consent was Denmark, and the United States.‍ CSF cultures.‍ Real-time reverse obtained