Parvovirus infection after laparoscopic hysterectomy using fibrin glue hemostasis

Parvovirus infection after laparoscopic hysterectomy using fibrin glue hemostasis Yutaka Morita, MD, Osamu Nishii, MD, Michiko Kido, MD, and Osamu Tsutsumi, MD Fibrin glue, a biologic hemostatic adhesive agent, is used in cardiovascular, thoracic, gynecologic, and neurologic surgery.1,2 We report a case in which human parvovirus B19, as a fibrin glue contaminant, caused severe postoperative leucocytopenia and reticulocytopenia in a nonimmunocompromised individual. A MEDLINE search from 1966 to 1999 using the search terms “fibrin glue,” and “parvovirus” identified no similar reports in the English literature. Case A 43-year-old Japanese woman, gravida 0, presented with severe menorrhagia and dysmenorrhea. Her medical history was uneventful. Pelvic ultrasound and magnetic resonance imaging (MRI) showed an adenomyomatous uterus (8.5 ⫻ 12.0 ⫻ 8.0 cm) and a left ovarian neoplasm (6.8 ⫻ 4.6 ⫻ 4.4 cm) consistent with endometrioma. After normal laboratory studies, including hematologic evaluation, she had a laparoscopically assisted vaginal hysterectomy, left salpingooophorectomy, and adhesiolysis. The cul-de-sac was obliterated, and after hysterectomy and adhesiolysis, moderate bleeding occurred from the right ovarian surface and rectal peritoneum, which could not be controlled by electrocauterization or sutures but was stopped by laparoscopically sealing the oozing surface with 3 mL of fibrin glue (Beriplast, Centeon, King of Prussia, PA). Her postoperative course was unremarkable until postoperative day 9 when chills and pyrexia (102F– 104F) developed with rapid onset of leucocytopenia (nadir of 1600/␮L on days 11 and 12). Despite parenteral iron therapy, her hemoglobin remained below 8.0 g/dL, and there were no reticulocytes in peripheral blood smears. Anti-parvovirus B19 immunoglobulin (Ig)M and IgG, measured by radioimmunoassay, became positive in the serum after day 13. Parvovirus B19 DNA was detected by polymerase chain reaction in the batch of fibrin glue used and in the woman’s serum on day 13. Evaluation of preoperative serum was negative for viral DNA and its antibodies. The pyrexia, leucocytopenia, and anemia improved gradually after day 15. There were no symptoms of arthralgia or erythema. The same batch of the fibrin glue used for other patients caused no problems. From the Department of Obstetrics and Gynecology, Tokyo University Branch Hospital, Tokyo, Japan.

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Comment Human parvovirus B19 causes an exanthem, erythema infectiosum, in children. An infected, healthy adult is either asymptomatic or has minor polyarthralgia syndrome, but in patients with underlying hemolysis, parvovirus B19 infection can cause abrupt, temporary cessation of erythropoiesis, ie, transient aplastic crisis. In our patient, who had acute surgical blood loss (800 mL), it is possible that the parvovirus B19 in the fibrin glue caused a typical aplastic crisis in a nonimmunocompromised individual. If blood transfusions had been given, this adverse effect might not have appeared because parovirus B19 infection occurs when erythropoiesis is activated. Fibrin glue consists of fibrinogen, thrombin, and factor XIII. No side effects have been reported. Parvovirus B19 has been shown to be transmissible by coagulation factor concentrates,3,4 and it is impossible to inactivate the virus by the current strategies used to make the products.3 In surgical patients who receive fibrin glue for extensive blood loss, careful postoperative observation is indicated. Manufacturers of fibrin glue and coagulation factor concentrates might look for alternative inactivation strategies and appropriate donor screening programs to reduce the risk of parvovirus infection.

References 1. Mouritzen C, Dromer M, Keineche HO. The effect of fibrin glueing to seal bronchial and alveolar leakages after pulmonary resections and decortications. Eur J Cardiothorac Surg 1993;7:75– 80. 2. Morita Y, Tsutsumi O, Momoeda M, Taketani Y. Cornual pregnancy successfully treated laparoscopically with fibrin glue hemostasis. Obstet Gynecol 1997;90:685–7. 3. Mortimer PP, Luban NLC, Kelleher JF, Cohen BJ. Transmission of serum parvovirus-like virus by clotting factor concentrates. Lancet 1983;2:482– 4. 4. Luban NLC. Human parvoviruses: Implications for transfusion medicine. Transfusion 1994;34:821–7.

Received January 10, 2000. Received in revised form February 29, 2000. Accepted March 24, 2000.

Copyright © 2000 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.

Obstetrics & Gynecology