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Parvovirus B19 infection mimicking juvenile myelomonocytic leukemia
International Journal of Infectious Diseases 14S (2010) e379–e380
Contents lists available at ScienceDirect
International Journal of Infectious Diseases journal homepage: www.elsevier.com/locate/ijid
Letter to the Editor Parvovirus B19 infection mimicking juvenile myelomonocytic leukemia We read with great interest ‘‘Transient leukoerythroblastosis in a very low birth weight infant with parvovirus B19 infection’’ by Duran et al.1 The authors describe a preterm infant with transient leukoerythroblastosis associated with a parvovirus B19 infection. Parvovirus B19 is a widespread virus, which shows tropism to bone marrow, particularly erythroid progenitor cells. In immunocompetent children, parvovirus B19 is the cause of erythema infectiosum. Transient hemolytic crisis is seen in those who have an underlying hemolytic disease. Parvovirus B19 is also a cause of cytopenia in children who have a congenital or acquired immune deficiency, such as organ transplant recipients and cancer patients.2 Leukoerythroblastosis is a rare disease that is characterized by leukocytosis and the presence of erythroid and myeloid blasts in the peripheral blood. The most common causes in children are viral infections and juvenile myelomonocytic leukemia (JMML). It can also be observed following osteopetrosis, myelofibrosis, and neuroblastoma.3–5 We report the case of a 2-month-old baby with a parvovirus B19 infection who initially presented with features of JMML. The patient was a twin pair male, born to non-related parents, weighing 2400 g. The prenatal and birth histories were unremarkable. He developed vomiting and reduced sucking on day 3 of life and was admitted to the neonatal intensive care unit with a diagnosis of sepsis. He was referred to our Pediatric Gastroenterohepatology Department with a distended abdomen and hepatosplenomegaly, which developed on follow-up.
[(Figure_1)TD$IG]
Figure 1. Bone marrow aspirate showing myelocytes, hypogranularity, and a blast (arrow) (Giemsa staining, original magnification 1000).
Physical examination revealed massive hepatosplenomegaly, widespread lymphadenomegaly, and no rash. Routine laboratory measurements showed significant leukocytosis (38.5 109/l), anemia (hemoglobin 9.2 g/dl and hematocrit 27.1%), and thrombocytopenia (96 109/l). Leukoerythroblastosis, monocytosis, and blast cells were noted in a peripheral blood smear. The reticulocyte ratio was 9.4%. Hemolytic anemia was ruled out because a direct Coombs test was negative and his bilirubin levels were within normal limits. As a viral infection and JMML were primarily considered, blood samples were sent for serological studies and TORCH panel (toxoplasmosis, rubella, cytomegalovirus, herpes simplex virus). A bone marrow aspiration was normocellular; 60% myelomonocytic cells and 3% blasts were present (Figure 1). Bone marrow cytogenetic examination was normal, and bcr–abl was negative. The patient’s viral serology results were positive for anti-parvovirus IgM and IgG. Intravenous immunoglobulin was started and the patient’s leukocytes decreased after the first dose. The patient is still on follow-up; repeated blood counts have been normal and the hepatosplenomegaly has improved. Leukoerythroblastosis mimicking JMML has been described in viral diseases such as cytomegalovirus and Epstein–Barr virus infections.6–8 Only four patients with parvovirus B19 infection and leukoerythroblastosis have previously been reported in the literature.1,3,8,9 Our case also shows that parvovirus B19 infection should be considered in the differential diagnosis of leukocytosis and that intravenous immunoglobulin treatment may be beneficial. Conflict of interest: No conflict of interest to declare. References 1. Duran R, Vatansever U, Acunas¸ B, Orhaner B, Demir M. Transient leukoerythroblastosis in a very low birth weight infant with parvovirus B19 infection. Int J Infect Dis 2009;13:473–5. 2. Zaki Mel S, Hassan SA, Seleim T, Lateef RA. Parvovirus B19 infection in children with a variety of hematological disorders. Hematology 2006;11:261–6. 3. Gulen H, Basarır F, Hakan N, Ciftdogan DY, Tansug N, Onag A. Premature labor and leukoerythroblastosis in a newborn with parvovirus B19 infection. Hematologica 2005;90(Suppl):ECR38. 4. Couselo Sanchez JM, Mendez RI, Fuster SM, Castro GM, Monasterio CL, Iglesias DL. Leukoerythroblastosis as a manifestation of disseminated neuroblastoma in childhood. Rev Esp Oncol 1980;27:571–8. 5. Pullarkat V, Bass RD, Gong JZ, Feinstein DI, Brynes RK. Primary autoimmune myelofibrosis: definition of a distinct clinicopathologic syndrome. Am J Hematol 2003;72:8–12. 6. Kirby MA, Weitzman S, Freedman MH. Juvenile chronic myelogenous leukemia: differentiation from infantile cytomegalovirus infection. Am J Pediatr Hematol Oncol 1990;12:292–6. 7. Herrod HG, Dow LW, Sullivan JL. Persistent Epstein–Barr virus infection mimicking juvenile chronic myelogenous leukemia: immunologic and hematologic studies. Blood 1983;61:1098–104. 8. Yetgin S, Cetin M, Yenicesu I, Ozaltin F, Uckan D. Acute parvovirus B19 infection mimicking juvenile myelomonocytic leukemia. Eur J Haematol 2000;65:276–8. 9. Gupta N, Gupta R, Bakhshi S. Transient myeloproliferation mimicking JMML associated with parvovirus infection of infancy. Pediatr Blood Cancer 2009;52: 411–3.
1201-9712/$36.00 – see front matter ß 2010 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijid.2010.04.004
e380
Letter to the Editor / International Journal of Infectious Diseases 14S (2010) e379–e380
¨ zdemira* Nihal O Hilal Akıb Handan Toptan Hakyemeza Fu¨gen C¸ullu C¸okug˘ras¸c Hilmi Apaka a Pediatric Hematology Department, Cerrahpas¸a Medical Faculty, Istanbul University, Istanbul, Turkey b Pathology Department, Cerrahpas¸a Medical Faculty, Istanbul University, Istanbul, Turkey
c
Pediatric Gastroenterology, Cerrahpas¸a Medical Faculty, Istanbul University, Istanbul, Turkey
*Corresponding author ¨ zdemir) E-mail address: [email protected] (N. O Corresponding Editor: William Cameron, Ottawa, Canada 24 March 2010 16 April 2010
Contents lists available at ScienceDirect
International Journal of Infectious Diseases journal homepage: www.elsevier.com/locate/ijid
Letter to the Editor Parvovirus B19 infection mimicking juvenile myelomonocytic leukemia We read with great interest ‘‘Transient leukoerythroblastosis in a very low birth weight infant with parvovirus B19 infection’’ by Duran et al.1 The authors describe a preterm infant with transient leukoerythroblastosis associated with a parvovirus B19 infection. Parvovirus B19 is a widespread virus, which shows tropism to bone marrow, particularly erythroid progenitor cells. In immunocompetent children, parvovirus B19 is the cause of erythema infectiosum. Transient hemolytic crisis is seen in those who have an underlying hemolytic disease. Parvovirus B19 is also a cause of cytopenia in children who have a congenital or acquired immune deficiency, such as organ transplant recipients and cancer patients.2 Leukoerythroblastosis is a rare disease that is characterized by leukocytosis and the presence of erythroid and myeloid blasts in the peripheral blood. The most common causes in children are viral infections and juvenile myelomonocytic leukemia (JMML). It can also be observed following osteopetrosis, myelofibrosis, and neuroblastoma.3–5 We report the case of a 2-month-old baby with a parvovirus B19 infection who initially presented with features of JMML. The patient was a twin pair male, born to non-related parents, weighing 2400 g. The prenatal and birth histories were unremarkable. He developed vomiting and reduced sucking on day 3 of life and was admitted to the neonatal intensive care unit with a diagnosis of sepsis. He was referred to our Pediatric Gastroenterohepatology Department with a distended abdomen and hepatosplenomegaly, which developed on follow-up.
[(Figure_1)TD$IG]
Figure 1. Bone marrow aspirate showing myelocytes, hypogranularity, and a blast (arrow) (Giemsa staining, original magnification 1000).
Physical examination revealed massive hepatosplenomegaly, widespread lymphadenomegaly, and no rash. Routine laboratory measurements showed significant leukocytosis (38.5 109/l), anemia (hemoglobin 9.2 g/dl and hematocrit 27.1%), and thrombocytopenia (96 109/l). Leukoerythroblastosis, monocytosis, and blast cells were noted in a peripheral blood smear. The reticulocyte ratio was 9.4%. Hemolytic anemia was ruled out because a direct Coombs test was negative and his bilirubin levels were within normal limits. As a viral infection and JMML were primarily considered, blood samples were sent for serological studies and TORCH panel (toxoplasmosis, rubella, cytomegalovirus, herpes simplex virus). A bone marrow aspiration was normocellular; 60% myelomonocytic cells and 3% blasts were present (Figure 1). Bone marrow cytogenetic examination was normal, and bcr–abl was negative. The patient’s viral serology results were positive for anti-parvovirus IgM and IgG. Intravenous immunoglobulin was started and the patient’s leukocytes decreased after the first dose. The patient is still on follow-up; repeated blood counts have been normal and the hepatosplenomegaly has improved. Leukoerythroblastosis mimicking JMML has been described in viral diseases such as cytomegalovirus and Epstein–Barr virus infections.6–8 Only four patients with parvovirus B19 infection and leukoerythroblastosis have previously been reported in the literature.1,3,8,9 Our case also shows that parvovirus B19 infection should be considered in the differential diagnosis of leukocytosis and that intravenous immunoglobulin treatment may be beneficial. Conflict of interest: No conflict of interest to declare. References 1. Duran R, Vatansever U, Acunas¸ B, Orhaner B, Demir M. Transient leukoerythroblastosis in a very low birth weight infant with parvovirus B19 infection. Int J Infect Dis 2009;13:473–5. 2. Zaki Mel S, Hassan SA, Seleim T, Lateef RA. Parvovirus B19 infection in children with a variety of hematological disorders. Hematology 2006;11:261–6. 3. Gulen H, Basarır F, Hakan N, Ciftdogan DY, Tansug N, Onag A. Premature labor and leukoerythroblastosis in a newborn with parvovirus B19 infection. Hematologica 2005;90(Suppl):ECR38. 4. Couselo Sanchez JM, Mendez RI, Fuster SM, Castro GM, Monasterio CL, Iglesias DL. Leukoerythroblastosis as a manifestation of disseminated neuroblastoma in childhood. Rev Esp Oncol 1980;27:571–8. 5. Pullarkat V, Bass RD, Gong JZ, Feinstein DI, Brynes RK. Primary autoimmune myelofibrosis: definition of a distinct clinicopathologic syndrome. Am J Hematol 2003;72:8–12. 6. Kirby MA, Weitzman S, Freedman MH. Juvenile chronic myelogenous leukemia: differentiation from infantile cytomegalovirus infection. Am J Pediatr Hematol Oncol 1990;12:292–6. 7. Herrod HG, Dow LW, Sullivan JL. Persistent Epstein–Barr virus infection mimicking juvenile chronic myelogenous leukemia: immunologic and hematologic studies. Blood 1983;61:1098–104. 8. Yetgin S, Cetin M, Yenicesu I, Ozaltin F, Uckan D. Acute parvovirus B19 infection mimicking juvenile myelomonocytic leukemia. Eur J Haematol 2000;65:276–8. 9. Gupta N, Gupta R, Bakhshi S. Transient myeloproliferation mimicking JMML associated with parvovirus infection of infancy. Pediatr Blood Cancer 2009;52: 411–3.
1201-9712/$36.00 – see front matter ß 2010 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijid.2010.04.004
e380
Letter to the Editor / International Journal of Infectious Diseases 14S (2010) e379–e380
¨ zdemira* Nihal O Hilal Akıb Handan Toptan Hakyemeza Fu¨gen C¸ullu C¸okug˘ras¸c Hilmi Apaka a Pediatric Hematology Department, Cerrahpas¸a Medical Faculty, Istanbul University, Istanbul, Turkey b Pathology Department, Cerrahpas¸a Medical Faculty, Istanbul University, Istanbul, Turkey
c
Pediatric Gastroenterology, Cerrahpas¸a Medical Faculty, Istanbul University, Istanbul, Turkey
*Corresponding author ¨ zdemir) E-mail address: [email protected] (N. O Corresponding Editor: William Cameron, Ottawa, Canada 24 March 2010 16 April 2010