Parvovirus B19 Mimicking Epstein-Barr Virus Infectious Mononucleosis in an Adult
2013; Elsevier BV; Volume: 126; Issue: 5 Linguagem: Inglês
10.1016/j.amjmed.2012.12.010
ISSN1555-7162
AutoresSigridh Muñoz-Gómez, Burke A. Cunha,
Tópico(s)Viral-associated cancers and disorders
ResumoEpstein-Barr virus is the cause of classic infectious mononucleosis. Other infections may mimic Epstein-Barr virus infectious mononucleosis, for example, cytomegalovirus, human herpes virus-6, toxoplasmosis, lymphoma, cat scratch fever, and rubella. Parvovirus B19 infections in children present as febrile exanthems; adults usually have small joint arthritis.Parvovirus B19 presents as a “flu-like” illness with low-grade fever, fatigue, malaise, and later, a rash may appear on the face (“slapped cheeks” appearance), trunk, or extremities (sparing the palms and soles) and is often accompanied/followed by small joint arthritis, which may be intermittent/persistent.1Woolf A.D. Campion G.V. Chishich A. et al.Clinical manifestations of human parvovirus B19 in adults.Arch Intern Med. 1989; 149: 1153-1156Crossref PubMed Google Scholar, 2Tsuda H. Maeda Y. Nakagawa K. Parvovirus B19-related lymphadenopathy.Br J Haematol. 1993; 85: 631-632Crossref PubMed Scopus (9) Google Scholar Cervical adenopathy is rare in adults. The differential diagnosis of Parvovirus B19 depends on its clinical manifestations. Adults with rash and small joint arthritis may mimic rubella. Parvovirus B19 immunoglobulin M (IgM) antibodies may cross-react with rubella IgM antibodies.2Tsuda H. Maeda Y. Nakagawa K. Parvovirus B19-related lymphadenopathy.Br J Haematol. 1993; 85: 631-632Crossref PubMed Scopus (9) Google Scholar Rash with cervical adenopathy occur with Epstein-Barr virus infectious mononucleosis, cytomegalovirus, or toxoplasmosis.3Reid D.M. Reid T.M.S. Brown T. et al.Human parvovirus-associated arthritis: a clinical and laboratory description.Lancet. 1985; 1: 422-425Abstract PubMed Scopus (314) Google Scholar Fatigue with cervical adenopathy suggests lymphoma, cat scratch disease, Epstein-Barr virus, or cytomegalovirus.4Evans L.M. Grossman M.E. Gregory N. Koplik spots and a purpuric eruption associated with parvovirus B19 infection.J Am Acad Dermatol. 1992; 27: 466-467Abstract Full Text PDF PubMed Scopus (41) Google Scholar False-positive Monospot tests may occur with rubella, toxoplasmosis, cytomegalovirus, Epstein-Barr virus, and Parvovirus B19.5Jones J.W. Pether J.V.S. Frost R.W.P. Human parvovirus B19 Hard to differentiate from infectious mononucleosis.Br Med J. 1994; 308: 595Crossref PubMed Scopus (9) Google Scholar We present a case of adult Parvovirus B19 mimicking Epstein-Barr virus infectious mononucleosis.6Hoagland R.J. Infectious Mononucleosis. Grune and Stratton, New York1967Google Scholar, 7Chin T. Diagnostic criteria and differential diagnosis.in: Schlossberg D. Infectious Mononucleosis. 2nd edition. Springer-Verlag, New York1989: 117-125Crossref Google Scholar, 8Chervenick P.A. Infectious mononucleosis: the classic clinical syndrome.in: Schlossberg D. Infectious Mononucleosis. 2nd edition. Springer-Verlag, New York1989: 29-34Crossref Google Scholar, 9Evans A.S. Infectious mononucleosis and related syndromes.Am J Med Sci. 1978; 276: 325-339Crossref PubMed Scopus (91) Google Scholar, 10Naito T. Kudo N. Inui A. et al.Causes of infectious mononucleosis-like syndrome in adult patients.Intern Med. 2006; 45: 833-834Crossref PubMed Scopus (11) Google ScholarCase ReportA 36-year-old woman presented with sore throat, fever, fatigue, and truncal rash. Throat culture was positive for group A streptococci. Physical examination was unremarkable except for bilateral posterior/anterior cervical adenopathy and tenderness of the interphalangeal joints. Laboratory testing included a white blood cell count of 5.2 K/mm3 (neutrophils=60%, lymphocytes = 24%, monocytes = 12%, and eosinophils = 4%) and an erythrocyte sedimentation rate of 5 mm/h. Serum transaminases were unelevated. Epstein-Barr virus viral capsid antigen IgM titer was negative, and Epstein-Barr virus viral capsid antigen immunoglobulin G (IgG) and nuclear antigen titers were positive. Cytomegalovirus IgM and IgG titers were negative. Rubella, human herpes virus-6, and Coxsackie B IgM and IgG titers were negative. Rheumatoid factors were not present, and her antinuclear antibody titer was negative. The antistreptolysin O titer was 93 IU/mL (n=<200 IU/mL). The Parvovirus B19 IgM titer was 12.0 IU (n=<0.8 IU) and IgG titer was 1.4 IU (n=0.8 IU). After a few months, her cervical lymphadenopathy and hand arthralgias resolved, but her fatigue persisted. She then recalled that her illness started 5 months before, during late winter, following a viral illness in her children.This case is remarkable in several respects. Firstly, bilateral posterior/anterior cervical adenopathy is rare with adult Parvovirus B19.4Evans L.M. Grossman M.E. Gregory N. Koplik spots and a purpuric eruption associated with parvovirus B19 infection.J Am Acad Dermatol. 1992; 27: 466-467Abstract Full Text PDF PubMed Scopus (41) Google Scholar Secondly, the patient was colonized with group A streptococci (positive culture but negative antistreptolysin O titer) as occurs in∼30% of Epstein-Barr virus infectious mononucleosis.6Hoagland R.J. Infectious Mononucleosis. Grune and Stratton, New York1967Google Scholar Fatigue was prominent, unusual for Parvovirus B19. Fatigue together with her cervical adenopathy mimicked Epstein-Barr virus infectious mononucleosis.6Hoagland R.J. Infectious Mononucleosis. Grune and Stratton, New York1967Google Scholar, 7Chin T. Diagnostic criteria and differential diagnosis.in: Schlossberg D. Infectious Mononucleosis. 2nd edition. Springer-Verlag, New York1989: 117-125Crossref Google Scholar, 8Chervenick P.A. Infectious mononucleosis: the classic clinical syndrome.in: Schlossberg D. Infectious Mononucleosis. 2nd edition. Springer-Verlag, New York1989: 29-34Crossref Google Scholar, 9Evans A.S. Infectious mononucleosis and related syndromes.Am J Med Sci. 1978; 276: 325-339Crossref PubMed Scopus (91) Google Scholar, 10Naito T. Kudo N. Inui A. et al.Causes of infectious mononucleosis-like syndrome in adult patients.Intern Med. 2006; 45: 833-834Crossref PubMed Scopus (11) Google Scholar Features distinguishing Parvovirus B19 from Epstein-Barr virus infectious mononucleosis was the absence of lymphocytosis, atypical lymphocytes, normal serum transaminases, and an unelevated erythrocyte sedimentation rate (Table).1Woolf A.D. Campion G.V. Chishich A. et al.Clinical manifestations of human parvovirus B19 in adults.Arch Intern Med. 1989; 149: 1153-1156Crossref PubMed Google Scholar, 2Tsuda H. Maeda Y. Nakagawa K. Parvovirus B19-related lymphadenopathy.Br J Haematol. 1993; 85: 631-632Crossref PubMed Scopus (9) Google Scholar, 3Reid D.M. Reid T.M.S. Brown T. et al.Human parvovirus-associated arthritis: a clinical and laboratory description.Lancet. 1985; 1: 422-425Abstract PubMed Scopus (314) Google Scholar, 7Chin T. Diagnostic criteria and differential diagnosis.in: Schlossberg D. Infectious Mononucleosis. 2nd edition. Springer-Verlag, New York1989: 117-125Crossref Google Scholar, 8Chervenick P.A. Infectious mononucleosis: the classic clinical syndrome.in: Schlossberg D. Infectious Mononucleosis. 2nd edition. Springer-Verlag, New York1989: 29-34Crossref Google Scholar, 9Evans A.S. Infectious mononucleosis and related syndromes.Am J Med Sci. 1978; 276: 325-339Crossref PubMed Scopus (91) Google Scholar, 10Naito T. Kudo N. Inui A. et al.Causes of infectious mononucleosis-like syndrome in adult patients.Intern Med. 2006; 45: 833-834Crossref PubMed Scopus (11) Google Scholar We believe this is the first reported case of adult Parvovirus B19 mimicking Epstein-Barr virus infectious mononucleosis.TableClinical and Laboratory Features of Parvovirus B19 vs EBV Infectious MononucleosisFeaturesParvovirus B19Epstein-Barr Virus Infectious MononucleosisSymptomsFever+⁎Mimics of Epstein Barr virus infectious mononucleosis.+Fatigue+⁎Mimics of Epstein Barr virus infectious mononucleosis.+Headache+/−⁎Mimics of Epstein Barr virus infectious mononucleosis.+/−Sore throat+/−+Early satiety−+/−Arthralgias+−SignsHoagland's sign−+Jaundice−+/−Exudative pharyngitis−+Nonexudative pharyngitis+⁎Mimics of Epstein Barr virus infectious mononucleosis.+Peripheral → central maculopapular rash+−Central → peripheral maculopapular rash−+Splenomegaly−+Arthritis+−Laboratory testsLeukopenia−⁎Mimics of Epstein Barr virus infectious mononucleosis.+/−Atypical lymphocytes−+Lymphocytosis−+Anemia+/−+/−Thrombocytopenia−+/−Elevated ESR−+Mildly elevated serum transaminases−+Throat culture for Group A streptococci+/−⁎Mimics of Epstein Barr virus infectious mononucleosis.+/−Elevated ASO titer−−Elevated Parvovirus B19 IgM titer+−Monospot test−+Elevated EBV VCA IgM−+Elevated EBV nuclear antigen−+ASO=antistreptolysin O titer; ESR=erythrocyte sedimentation rate; VCA=viral capsid antigen. Mimics of Epstein Barr virus infectious mononucleosis. Open table in a new tab Epstein-Barr virus is the cause of classic infectious mononucleosis. Other infections may mimic Epstein-Barr virus infectious mononucleosis, for example, cytomegalovirus, human herpes virus-6, toxoplasmosis, lymphoma, cat scratch fever, and rubella. Parvovirus B19 infections in children present as febrile exanthems; adults usually have small joint arthritis. Parvovirus B19 presents as a “flu-like” illness with low-grade fever, fatigue, malaise, and later, a rash may appear on the face (“slapped cheeks” appearance), trunk, or extremities (sparing the palms and soles) and is often accompanied/followed by small joint arthritis, which may be intermittent/persistent.1Woolf A.D. Campion G.V. Chishich A. et al.Clinical manifestations of human parvovirus B19 in adults.Arch Intern Med. 1989; 149: 1153-1156Crossref PubMed Google Scholar, 2Tsuda H. Maeda Y. Nakagawa K. Parvovirus B19-related lymphadenopathy.Br J Haematol. 1993; 85: 631-632Crossref PubMed Scopus (9) Google Scholar Cervical adenopathy is rare in adults. The differential diagnosis of Parvovirus B19 depends on its clinical manifestations. Adults with rash and small joint arthritis may mimic rubella. Parvovirus B19 immunoglobulin M (IgM) antibodies may cross-react with rubella IgM antibodies.2Tsuda H. Maeda Y. Nakagawa K. Parvovirus B19-related lymphadenopathy.Br J Haematol. 1993; 85: 631-632Crossref PubMed Scopus (9) Google Scholar Rash with cervical adenopathy occur with Epstein-Barr virus infectious mononucleosis, cytomegalovirus, or toxoplasmosis.3Reid D.M. Reid T.M.S. Brown T. et al.Human parvovirus-associated arthritis: a clinical and laboratory description.Lancet. 1985; 1: 422-425Abstract PubMed Scopus (314) Google Scholar Fatigue with cervical adenopathy suggests lymphoma, cat scratch disease, Epstein-Barr virus, or cytomegalovirus.4Evans L.M. Grossman M.E. Gregory N. Koplik spots and a purpuric eruption associated with parvovirus B19 infection.J Am Acad Dermatol. 1992; 27: 466-467Abstract Full Text PDF PubMed Scopus (41) Google Scholar False-positive Monospot tests may occur with rubella, toxoplasmosis, cytomegalovirus, Epstein-Barr virus, and Parvovirus B19.5Jones J.W. Pether J.V.S. Frost R.W.P. Human parvovirus B19 Hard to differentiate from infectious mononucleosis.Br Med J. 1994; 308: 595Crossref PubMed Scopus (9) Google Scholar We present a case of adult Parvovirus B19 mimicking Epstein-Barr virus infectious mononucleosis.6Hoagland R.J. Infectious Mononucleosis. Grune and Stratton, New York1967Google Scholar, 7Chin T. Diagnostic criteria and differential diagnosis.in: Schlossberg D. Infectious Mononucleosis. 2nd edition. Springer-Verlag, New York1989: 117-125Crossref Google Scholar, 8Chervenick P.A. Infectious mononucleosis: the classic clinical syndrome.in: Schlossberg D. Infectious Mononucleosis. 2nd edition. Springer-Verlag, New York1989: 29-34Crossref Google Scholar, 9Evans A.S. Infectious mononucleosis and related syndromes.Am J Med Sci. 1978; 276: 325-339Crossref PubMed Scopus (91) Google Scholar, 10Naito T. Kudo N. Inui A. et al.Causes of infectious mononucleosis-like syndrome in adult patients.Intern Med. 2006; 45: 833-834Crossref PubMed Scopus (11) Google Scholar Case ReportA 36-year-old woman presented with sore throat, fever, fatigue, and truncal rash. Throat culture was positive for group A streptococci. Physical examination was unremarkable except for bilateral posterior/anterior cervical adenopathy and tenderness of the interphalangeal joints. Laboratory testing included a white blood cell count of 5.2 K/mm3 (neutrophils=60%, lymphocytes = 24%, monocytes = 12%, and eosinophils = 4%) and an erythrocyte sedimentation rate of 5 mm/h. Serum transaminases were unelevated. Epstein-Barr virus viral capsid antigen IgM titer was negative, and Epstein-Barr virus viral capsid antigen immunoglobulin G (IgG) and nuclear antigen titers were positive. Cytomegalovirus IgM and IgG titers were negative. Rubella, human herpes virus-6, and Coxsackie B IgM and IgG titers were negative. Rheumatoid factors were not present, and her antinuclear antibody titer was negative. The antistreptolysin O titer was 93 IU/mL (n=<200 IU/mL). The Parvovirus B19 IgM titer was 12.0 IU (n=<0.8 IU) and IgG titer was 1.4 IU (n=0.8 IU). After a few months, her cervical lymphadenopathy and hand arthralgias resolved, but her fatigue persisted. She then recalled that her illness started 5 months before, during late winter, following a viral illness in her children.This case is remarkable in several respects. Firstly, bilateral posterior/anterior cervical adenopathy is rare with adult Parvovirus B19.4Evans L.M. Grossman M.E. Gregory N. Koplik spots and a purpuric eruption associated with parvovirus B19 infection.J Am Acad Dermatol. 1992; 27: 466-467Abstract Full Text PDF PubMed Scopus (41) Google Scholar Secondly, the patient was colonized with group A streptococci (positive culture but negative antistreptolysin O titer) as occurs in∼30% of Epstein-Barr virus infectious mononucleosis.6Hoagland R.J. Infectious Mononucleosis. Grune and Stratton, New York1967Google Scholar Fatigue was prominent, unusual for Parvovirus B19. Fatigue together with her cervical adenopathy mimicked Epstein-Barr virus infectious mononucleosis.6Hoagland R.J. Infectious Mononucleosis. Grune and Stratton, New York1967Google Scholar, 7Chin T. Diagnostic criteria and differential diagnosis.in: Schlossberg D. Infectious Mononucleosis. 2nd edition. Springer-Verlag, New York1989: 117-125Crossref Google Scholar, 8Chervenick P.A. Infectious mononucleosis: the classic clinical syndrome.in: Schlossberg D. Infectious Mononucleosis. 2nd edition. Springer-Verlag, New York1989: 29-34Crossref Google Scholar, 9Evans A.S. Infectious mononucleosis and related syndromes.Am J Med Sci. 1978; 276: 325-339Crossref PubMed Scopus (91) Google Scholar, 10Naito T. Kudo N. Inui A. et al.Causes of infectious mononucleosis-like syndrome in adult patients.Intern Med. 2006; 45: 833-834Crossref PubMed Scopus (11) Google Scholar Features distinguishing Parvovirus B19 from Epstein-Barr virus infectious mononucleosis was the absence of lymphocytosis, atypical lymphocytes, normal serum transaminases, and an unelevated erythrocyte sedimentation rate (Table).1Woolf A.D. Campion G.V. Chishich A. et al.Clinical manifestations of human parvovirus B19 in adults.Arch Intern Med. 1989; 149: 1153-1156Crossref PubMed Google Scholar, 2Tsuda H. Maeda Y. Nakagawa K. Parvovirus B19-related lymphadenopathy.Br J Haematol. 1993; 85: 631-632Crossref PubMed Scopus (9) Google Scholar, 3Reid D.M. Reid T.M.S. Brown T. et al.Human parvovirus-associated arthritis: a clinical and laboratory description.Lancet. 1985; 1: 422-425Abstract PubMed Scopus (314) Google Scholar, 7Chin T. Diagnostic criteria and differential diagnosis.in: Schlossberg D. Infectious Mononucleosis. 2nd edition. Springer-Verlag, New York1989: 117-125Crossref Google Scholar, 8Chervenick P.A. Infectious mononucleosis: the classic clinical syndrome.in: Schlossberg D. Infectious Mononucleosis. 2nd edition. Springer-Verlag, New York1989: 29-34Crossref Google Scholar, 9Evans A.S. Infectious mononucleosis and related syndromes.Am J Med Sci. 1978; 276: 325-339Crossref PubMed Scopus (91) Google Scholar, 10Naito T. Kudo N. Inui A. et al.Causes of infectious mononucleosis-like syndrome in adult patients.Intern Med. 2006; 45: 833-834Crossref PubMed Scopus (11) Google Scholar We believe this is the first reported case of adult Parvovirus B19 mimicking Epstein-Barr virus infectious mononucleosis.TableClinical and Laboratory Features of Parvovirus B19 vs EBV Infectious MononucleosisFeaturesParvovirus B19Epstein-Barr Virus Infectious MononucleosisSymptomsFever+⁎Mimics of Epstein Barr virus infectious mononucleosis.+Fatigue+⁎Mimics of Epstein Barr virus infectious mononucleosis.+Headache+/−⁎Mimics of Epstein Barr virus infectious mononucleosis.+/−Sore throat+/−+Early satiety−+/−Arthralgias+−SignsHoagland's sign−+Jaundice−+/−Exudative pharyngitis−+Nonexudative pharyngitis+⁎Mimics of Epstein Barr virus infectious mononucleosis.+Peripheral → central maculopapular rash+−Central → peripheral maculopapular rash−+Splenomegaly−+Arthritis+−Laboratory testsLeukopenia−⁎Mimics of Epstein Barr virus infectious mononucleosis.+/−Atypical lymphocytes−+Lymphocytosis−+Anemia+/−+/−Thrombocytopenia−+/−Elevated ESR−+Mildly elevated serum transaminases−+Throat culture for Group A streptococci+/−⁎Mimics of Epstein Barr virus infectious mononucleosis.+/−Elevated ASO titer−−Elevated Parvovirus B19 IgM titer+−Monospot test−+Elevated EBV VCA IgM−+Elevated EBV nuclear antigen−+ASO=antistreptolysin O titer; ESR=erythrocyte sedimentation rate; VCA=viral capsid antigen. Mimics of Epstein Barr virus infectious mononucleosis. Open table in a new tab A 36-year-old woman presented with sore throat, fever, fatigue, and truncal rash. Throat culture was positive for group A streptococci. Physical examination was unremarkable except for bilateral posterior/anterior cervical adenopathy and tenderness of the interphalangeal joints. Laboratory testing included a white blood cell count of 5.2 K/mm3 (neutrophils=60%, lymphocytes = 24%, monocytes = 12%, and eosinophils = 4%) and an erythrocyte sedimentation rate of 5 mm/h. Serum transaminases were unelevated. Epstein-Barr virus viral capsid antigen IgM titer was negative, and Epstein-Barr virus viral capsid antigen immunoglobulin G (IgG) and nuclear antigen titers were positive. Cytomegalovirus IgM and IgG titers were negative. Rubella, human herpes virus-6, and Coxsackie B IgM and IgG titers were negative. Rheumatoid factors were not present, and her antinuclear antibody titer was negative. The antistreptolysin O titer was 93 IU/mL (n=<200 IU/mL). The Parvovirus B19 IgM titer was 12.0 IU (n=<0.8 IU) and IgG titer was 1.4 IU (n=0.8 IU). After a few months, her cervical lymphadenopathy and hand arthralgias resolved, but her fatigue persisted. She then recalled that her illness started 5 months before, during late winter, following a viral illness in her children. This case is remarkable in several respects. Firstly, bilateral posterior/anterior cervical adenopathy is rare with adult Parvovirus B19.4Evans L.M. Grossman M.E. Gregory N. Koplik spots and a purpuric eruption associated with parvovirus B19 infection.J Am Acad Dermatol. 1992; 27: 466-467Abstract Full Text PDF PubMed Scopus (41) Google Scholar Secondly, the patient was colonized with group A streptococci (positive culture but negative antistreptolysin O titer) as occurs in∼30% of Epstein-Barr virus infectious mononucleosis.6Hoagland R.J. Infectious Mononucleosis. Grune and Stratton, New York1967Google Scholar Fatigue was prominent, unusual for Parvovirus B19. Fatigue together with her cervical adenopathy mimicked Epstein-Barr virus infectious mononucleosis.6Hoagland R.J. Infectious Mononucleosis. Grune and Stratton, New York1967Google Scholar, 7Chin T. Diagnostic criteria and differential diagnosis.in: Schlossberg D. Infectious Mononucleosis. 2nd edition. Springer-Verlag, New York1989: 117-125Crossref Google Scholar, 8Chervenick P.A. Infectious mononucleosis: the classic clinical syndrome.in: Schlossberg D. Infectious Mononucleosis. 2nd edition. Springer-Verlag, New York1989: 29-34Crossref Google Scholar, 9Evans A.S. Infectious mononucleosis and related syndromes.Am J Med Sci. 1978; 276: 325-339Crossref PubMed Scopus (91) Google Scholar, 10Naito T. Kudo N. Inui A. et al.Causes of infectious mononucleosis-like syndrome in adult patients.Intern Med. 2006; 45: 833-834Crossref PubMed Scopus (11) Google Scholar Features distinguishing Parvovirus B19 from Epstein-Barr virus infectious mononucleosis was the absence of lymphocytosis, atypical lymphocytes, normal serum transaminases, and an unelevated erythrocyte sedimentation rate (Table).1Woolf A.D. Campion G.V. Chishich A. et al.Clinical manifestations of human parvovirus B19 in adults.Arch Intern Med. 1989; 149: 1153-1156Crossref PubMed Google Scholar, 2Tsuda H. Maeda Y. Nakagawa K. Parvovirus B19-related lymphadenopathy.Br J Haematol. 1993; 85: 631-632Crossref PubMed Scopus (9) Google Scholar, 3Reid D.M. Reid T.M.S. Brown T. et al.Human parvovirus-associated arthritis: a clinical and laboratory description.Lancet. 1985; 1: 422-425Abstract PubMed Scopus (314) Google Scholar, 7Chin T. Diagnostic criteria and differential diagnosis.in: Schlossberg D. Infectious Mononucleosis. 2nd edition. Springer-Verlag, New York1989: 117-125Crossref Google Scholar, 8Chervenick P.A. Infectious mononucleosis: the classic clinical syndrome.in: Schlossberg D. Infectious Mononucleosis. 2nd edition. Springer-Verlag, New York1989: 29-34Crossref Google Scholar, 9Evans A.S. Infectious mononucleosis and related syndromes.Am J Med Sci. 1978; 276: 325-339Crossref PubMed Scopus (91) Google Scholar, 10Naito T. Kudo N. Inui A. et al.Causes of infectious mononucleosis-like syndrome in adult patients.Intern Med. 2006; 45: 833-834Crossref PubMed Scopus (11) Google Scholar We believe this is the first reported case of adult Parvovirus B19 mimicking Epstein-Barr virus infectious mononucleosis. ASO=antistreptolysin O titer; ESR=erythrocyte sedimentation rate; VCA=viral capsid antigen.
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