Long-Term IVIG Therapy Demonstrates Excellent Response in Patient with HIV, Persistent Parvovirus Infection Causing Anemia

A recent case report published in Cureus demonstrated that long-term maintenance intravenous immunoglobulin (IVIG) therapy resulted in an excellent therapeutic response in a patient with HIV and a chronic parvovirus infection resulting in chronic anemia.

According to the authors, anemia is a common finding in patients with HIV and has a wide range of potential causes. Opportunistic parvovirus infection, which causes pure red cell aplasia, is an uncommon cause of anemia; although, immunocompromised patients with abnormal antibody production may be more susceptible to acquiring a chronic parvovirus infection requiring long-term IVIG treatment. However, there are no specific guidelines for these patients.

Parvovirus is typically transmitted through respiratory droplets, although it can also be transmitted through other means, such as blood products and organ transplants. Acute parvovirus can cause transient aplastic crises and pure red cell aplasia with persistent infection by infecting the erythroid precursors in the bone marrow. Immunocompromised patients are particularly at risk of developing persistent and severe anemia caused by parvovirus infections.

Furthermore, these patients are susceptible to infection relapses, which highlights the importance of ongoing monitoring and maintenance therapy. IVIG is an effective treatment for parvovirus-induced pure red cell aplasia, but there are no specific treatment guidelines for chronic parvovirus infection.

In the case presentation, a 38-year-old Hispanic man with HIV presented to the emergency department (ED) with severe fatigue and palpitations for 1 week. His initial laboratory findings showed a hemoglobin level of 3.3 g/dl with normocytic normochromic red blood cells, and his baseline hemoglobin 1 year prior was 11 g/dl. He said he had not taken his HIV medications for the past year and did receive blood transfusions in the ED.

The patient was provisionally diagnosed with chronic parvovirus infection with pure red cell aplasia causing severe anemia and received IVIG of 2 g/kg total dose. He was also restarted on anti-retroviral medication, including an emtricitabine-rilpivirine-tenofovir combination of 1 tablet daily.

By the time he was discharged, his blood counts responded, and his hemoglobin was stable at 7.2 g/dl. However, he had persistent viral titers of parvovirus B19 and did not follow up in the clinic.

Approximately 6 months later, the patient relapsed and presented to the ED with a hemoglobin of 4.8 g/dl and normocytic normochromic anemia. After multiple blood transfusions, his hemoglobin stabilized at 9.3 g/dl and he was subsequently discharged.

At follow-up in 2 weeks, hemoglobin levels dropped to 6.7 g/dl and he was treated with IVIG 1 g/kg every 2 days. Since then, he has been receiving monthly IVIG maintenance of 0.4 g/kg for the past year.

While on maintenance IVIG, the patient has not required breakthrough blood transfusions or hospitalizations. Importantly, he has reported improved adherence to the highly active antiretroviral therapy regimen, with gradual improvement in CD4 counts and decreasing viral load. Parvovirus levels fell but continued to be detectable, suggesting chronic infection, according to the study.

Based on these findings and other reports of patients receiving IVIG for several months for chronic parvovirus infection, the researchers said IVIG is an effective treatment for parvovirus-induced pure red cell aplasia. The infused antibodies contain large amounts of anti-HPV-B19 immunoglobulin and therefore can neutralize the virus.

However, the authors noted that it is challenging to determine the optimal dose and duration of IVIG treatment for patients with chronic parvovirus infection to minimize relapses and hospitalizations. In order to define further treatment guidelines, they said prospective studies analyzing the efficacy of chronic maintenance therapy should be conducted.

REFERENCE

Gor D, Singh V, Gupta V, et al. (April 30, 2022) A Persistent Parvovirus Infection Causing Anemia in an HIV Patient Requiring Intravenous Immunoglobulin Maintenance Therapy. Cureus 14(4): e24627. doi:10.7759/cureus.24627