Revista do Instituto de Medicina Tropical de São
Paulo
Print version ISSN 0036-4665
Rev. Inst.
Med. trop. S.
Paulo vol.44 no.4 São Paulo July/Aug. 2002
doi: 10.1590/S0036-46652002000400002
STUDY OF CHRONIC HEMOLYTIC ANAEMIA PATIENTS IN RIO DE JANEIRO: PREVALENCE
OF ANTI-HUMAN PARVOVIRUS B19 IgG ANTIBODIES AND THE DEVELOPEMENT APLASTIC
CRISES
Anadayr
L.M. SANT'ANNA(1) Rita de Cássia N. Cubel
GARCIA(2), Mônica MARZOCHE(3), Heloisa Helena A. Gallo
da ROCHA(1), Maria Tereza M. PAULA(1), Clarisse C. LOBO(1) & Jussara P.
NASCIMENTO(2,3,4,)
SUMMARY
The prevalence of
anti-human parvovirus B19 IgG antibodies was determined in sera from 165
chronic hemolytic anemia patients, receiving medical care at Instituto Estadual
de Hematologia (IEHE), Rio de Janeiro, during the year of 1994. This sample
represents around 10% of the chronic hemolytic anemia patients attending at
IEHE. Most of these patients (140) have sickle cell disease. Anti-B19 IgG
antibodies were detected in 32.1% of patients. No statistically significant
difference (p > 0.05) was seen between IgG antibody prevalence in
male (27.8%) and female (35.5%) patients. Anti-B19 IgG antibodies were more
frequent in older (37.6%) than younger (28.2%) than 20 years old patients,
although this difference had no statistical significance (p > 0.05).
Anti-B19 IgG antibody prevalence showed that 67.9% of patients enrolled in the
study were susceptible to B19 acute infection. With the aim to detect acute B19
infection, patients follow up continued until February 1996. During this period
four patients presented transient aplastic crisis due to human parvovirus B19
as confirmed by the detection of specific IgM antibodies. All four patients
were younger than 20 years old, and 3 were younger than 10 years old. Three of
them were sickle cell disease patients. Three of the four acute B19 infection
occurred during 1994 springtime.
KEYWORDS: Human Parvovirus B19;
Sickle-cell disease; Transient aplastic crisis
INTRODUCTION
Human parvovirus B19,
discovered in 1974 by COSSART et al.7, is now recognized as
an important human pathogen causing erythema infectiosum or fifth disease in
normal children and occurring worldwide. Other pathogenic presentations
depending of host conditions are transient aplastic crisis (TAC) in chronic
hemolytic anaemia patients, pure red blood cell aplasia (PRBCA) in
immunosuppressed patients, and non-immune hydrops fetalis (NIHF) when infection
occurs in pregnant women5. These clinical presentations are related
to the tropism of the virus for bone marrow precursors, mainly erythroblasts23.
TAC in chronic hemolytic anaemia patients is characterized by profound
reticulocytopenia and worsening anaemia. Most patients require red blood cell
transfusion and TAC is one of possible fatal events in sickle cell anemia17,30.
Sickle cell disease is the most common chronic hemolytic anaemia in Brazil and
one of the most important genetic diseases in this country27. We
have studied the human parvovirus B19 circulation in Brazil since 1988, when we
found an asymptomatic viremic blood donor in Rio de Janeiro9.
Infection is widespread in Rio de Janeiro city where anti-B19 IgG antibodies
were found in 73.7% of the sera collected during 1985 and 198625.
Clinical presentations such as TAC in hereditary spherocytosis and sickle cell
patients13, fifth disease12,26, NIHF11,16 were
also described by us in Rio de Janeiro, and other Brazilian States during the
last decade. We are reporting here a 20 months follow up, hold during 1994 to
1996, in a cohort of chronic hemolytic anemia patients attending at Instituto
Estadual de Hematologia in Rio de Janeiro.
MATERIALS AND
METHODS
Patients: 165 anemic patients were
selected from a total of 1629 attending at IEHE during the period of June to
December 1994, in order to verify the anti-B19 IgG antibodies prevalence. This
sample represents around 10% of the patients and the description of this
population is shown in Table 1. During the period from
June 1994 to February 1996, nineteen patients suspecting to present TAC (HT
< 20% or Hb < 8 mg%), were tested for acute human parvovirus B19
infection. Another five patients sharing the same ward of a B19 positive TAC
patient during November 1994 were also included in this study. This project
obtained the approval by the Ethical Research Council of IEHE.
Serum specimens: Blood samples were taken
by vein puncture, and sera were stored at -20 °C until tested.
Laboratory diagnosis: Anti-B19 IgG and IgM
antibodies were tested by in house enzyme immuno assays, using
µ-antibody capture-MACEIA10 and a direct IgG test12.
Viremia was analyzed by B19 DNA detection by dot-blot hybridization assay using
a biotin-labeled probe22.
Statistical tests: The chi square test with
Yates' correction was used to analyze anti-B19 IgG results.
RESULTS
From a total of 1629 anemic
patients attending at IEHE during 1994, 165 blood samples were collected to
study anti-B19 IgG antibody prevalence. Most of these patients (1125) have
sickle cell disease so 140 from 165 blood samples were collected from SCD
patients (Table 1). Only 25 blood samples
were collected from patients presenting another type of hemolytic disease:
chronic (21) or acquired (4). As shown in Table 2, 32.1% of these patients
were immune to B19 parvovirus and 67.9 % remaining susceptible to the virus. In
this group of patients 93 were females and 72 were males. No difference in IgG
antibodies prevalence was noticed between these groups. The age distribution of
the patients showed that the patients less than 20 years old had lower antibody
prevalence than older patients. During the 20 months follow up, 19 patients
were suspected to present TAC and anti-B19 IgM could be detected in only 4 (Table 3). None of them had B19 DNA
in the sample tested. The B19 positive acute infections were detected during
the months of September, October, November 1994 and May 1995. One of these
patients has hereditary spherocytosis and the other three were sickle cell
disease patients. All four patients were less than 20 years old and three of
them were less than 10 years old. Table 4 shows the laboratory
results of 5 patients that shared the same ward with one B19 positive TAC
patient during November 1994. None of them became infected, although three were
immunosuppressed and two of them were already immune to the virus.
DISCUSSION
Infection by the human
parvovirus B19 is widespread and it occurs in all regions where it has been
studied. Around 50% of people have anti-B19 antibodies by the age of 15 years
old. Infection continues to occur in adult life and around 80% of the
population is immune to the virus by the age of 50 years old6. The
same antibody distribution was described in USA3, France8,
Germany33 and Japan24, but for some countries like Brazil25
and Africa32 the antibody prevalence can be higher. Some isolated
Indian populations showed lower antibody prevalence as described in Brazilian
Amazon15 and some regions in Africa29. We describe here
anti-B19 antibody prevalence in a sample of 10% of chronic hemolytic anemia
patients receiving medical care at IEHE, RJ. Previous immunity to B19 was
detected in 32.1% of the patients; this number is very low as compared to
previous results (73.7%) obtained in Rio de Janeiro general population25
during 1985/1986. There is no difference regarding sex as also described in the
previous study25. As shown in Table 2, 41.8% of the patients
were more than 20 years old. It was expected that these older people should
have higher antibodies prevalence if we compare with other prevalence studies3,6,8,24,29,33
and knowing that B19 acute infection occurs mainly in scholars and teenagers6.
In our group of patients, age was not associated with seropositivity to B19.
Antibody prevalence increased with the age group from 26.6 (less than 10 years
old) to 37.6 (more than 20 years old), although suggestive this difference did
not achieve statistical significance (p > 0.05). EI outbreaks occur
in intervals of 3 to 4 years3,6, during the end of the winter,
springtime and beginning of summer2. In Asian countries the
epidemiology of B19 infection is quite distinct. The antibody prevalence is
very low in Hong Kong19, Singapore21 and Taiwan20,
when compared to countries in Occident. Intervals of 10 years between outbreaks
have been described in Japan34. These results suggested that
anti-B19 antibody prevalence could be lower during pre-epidemic periods. In our
study we use sera collected during 1994 (end of winter to beginning of summer),
when we had an EI outbreak in Rio de Janeiro city12,26. This can
explain why we had so low antibody prevalence in our patients. Another
possibility to explain our data is the severity of infection in this group that
leads to TAC being fatal when blood transfusions were not performed on time.
The risk of death by TAC is described in SCD patients17,30 although
a study hold in Africa did not show any difference in anti-B19 IgG antibody
prevalence between SCD patients and normal population in sera collected during
the same epidemiological period31. Table 3 shows the results of 19
patients showing TAC during the studied period (June, 1994 to February, 1996).
All but 7 patients were less than 20 years old, as also the 4 patients that had
laboratorial confirmation (by specific IgM detection) of B19 acute infection.
Three of these 4 patients were less than 10 years old according to other
papers, which report that B19 acute infection is more frequent at this age
range3,6,8,24,29,33. All 4 but one confirmed cases occurred during
1994 springtime, the other case occurred in the beginning of winter 1995. These
cases confirm the seasonality described for other countries, and also for Rio
de Janeiro after 12 years of consecutive studies9,10,13. Among these
4 patients only one was also positive for anti-B19 IgG. It shows that sera were
collected early during the infection but not during viremia (all 4 patients
were B19 DNA negative), which normally occurs together with TAC symptoms14.
B19 DNA detection is very important in TAC patients because anti-B19 IgM
antibodies can be not found in the beginning of the symptoms. The laboratorial
diagnosis of TAC is quite different from EI cases when anti-B19 antibodies (IgM
and IgG) were almost present when rash mediated by antigen-antibodies complex
appears12. During November 1994 a TAC patient were in a ward
together with 5 other patients (Table 4). None of them developed
TAC, although 3 of them was susceptible to the infection (anti-B19 IgG
negative). For 3 of these patients the diagnosis was acute myeloblastic
leukaemia (immunosuppressed), that could develop persistent B19 infection18.
Therefore two of them were immune to the virus (anti-B19 IgG positive). TAC
patients are highly infectious for hospital staff and other patients having
contact with them4. Normally, TAC symptoms occur during viremia
(peak of virus around 1014 particles/ml), and patients eliminate
high quantity of virus by respiratory route1.
We conclude that
laboratorial diagnosis of acute B19 infections is very important in patients in
haematology wards, making possible better prognosis of the cases, lower
clinical cost and lower risk for inpatients. These will be more important if we
consider that, during 1994, 67.9% of the patients were still susceptible to B19
infection.
RESUMO
Estudo
de pacientes com anemia hemolítica crônica no Rio de Janeiro: prevalência de
anticorpos IgG anti-parvovirus humano B19 e desenvolvimento de crise aplástica
transitória
A
prevalência de anticorpos anti-parvovirus humano B19 foi determinada em soros
de 165 pacientes portadores de anemia hemolítica crônica, atendidos no
Instituto Estadual de Hematologia (IEHE), Rio de Janeiro, durante o ano de
1994. Esta amostra representa cerca de 10% dos pacientes portadores de anemia
hemolítica crônica atendidos no IEHE. A maioria destes pacientes (140) são
portadores de anemia falciforme. Anticorpos IgG anti-parvovirus humano B19
foram detectados em 32,1% dos pacientes. Nenhuma diferença estatisticamente
significante foi verificada entre a prevalência de anticorpos em pacientes do
sexo masculino (27,8%) e feminino (35,5%). Anticorpos IgG anti-parvovirus
humano B19 foram mais freqüentes em pacientes na faixa etária acima (37,8%) que
abaixo (28,2%) de 20 anos de idade, embora esta diferença não tenha significado
estatístico (p > 0,05). A prevalência de anticorpos IgG anti-B19
demonstrou que 67,9% dos pacientes incluídos no estudo eram ainda suscetíveis à
infecção aguda pelo parvovirus humano B19. Com o objetivo de detectar infecção
aguda por este vírus, o seguimento de pacientes continuou até fevereiro de
1996. Durante este período, 4 pacientes apresentaram crise de aplasia transitória
devido ao parvovirus humano B19 conforme confirmado pela detecção de anticorpos
IgM específicos. Todos 4 pacientes estavam na faixa etária abaixo de 20 anos,
sendo que 3 tinham menos de 10 anos de idade. Três destes pacientes eram
portadores de anemia falciforme. Em 3 dos 4 pacientes, a infecção aguda por B19
ocorreu durante a primavera de 1994.
ACKNOWLEDGEMENTS
We
are indebted to Drs Kátia Machado da Motta, Marília Ruggani, Márcia Villanova
and the nursing staff of Instituto Estadual de Hematologia Arthur da Siqueira
Cavalcanti for patients' selection and collecting blood samples, to Renata F.A.
Pereira and Ana Cristina Alferes for technical assistance, to Dr Silvio Torres
for statistical analysis and to Dr Maria José Andrada Serpa for helpful discussions.
This work is partially
supported by grants from CNPq, CAPES, The British Council and FAPERJ, Brazil.
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Received: 03 May 2002
Accepted: 04 June 2002
(1) Instituto Estadual de
Hematologia Arthur de Siqueira Cavalcanti, SES/RJ. Rua Frei Caneca 8, 20211-030
Rio de Janeiro, RJ, Brasil.
(2) Instituto Biomédico, UFF. Rua
Hernani Mello 101, 24210-130 Niterói, RJ, Brasil
(3) Instituto Oswaldo Cruz,
Av. Brasil 4365, 21045-900 Rio de Janeiro, RJ, Brasil.
(4) Instituto de Tecnologia
em Imunobiológicos, FIOCRUZ. Av. Brasil 4365, 21045-900 Rio de Janeiro, RJ,
Brasil.