revised April 2, 2002 

Transient Aplastic Crisis in Hemolytic Anemias


 All people with hemolytic anemias rely on high erythrocyte production rates to maintain adequate hemoglobin levels. Examples include sickle cell disease, thalassemia intermedia, and severe pyruvate kinase deficiency. If the capacity of the bone marrow to manufacture new red cells is compromised, the hematocrit can dramatically fall to levels that are potentially deadly.

Viral infections

Table 1- Manifestations of Parvovirus B19 Infection in Acute Host
Acute Host Disease
Normal child Fifth's Disease
Normal adult Polyarthropathy
Chronic hemolytic anemia Transient aplastic crisis

 Many types of viral infections can suppress bone marrow activity. The most important etiologic agent in transient aplastic crisis is parvovirus B19 (1). The genome of this virus, one of the smallest known, consists of single-stranded DNA. The virus commonly causes the childhood illness, "Fifth Disease", which usually is a minor ailment. Malaise, low-grade fever, arthralgias and a skin rash (often manifested as red, "slapped", cheeks) are hallmarks of the condition. Parvovirus B19 infection in adults frequently is associated with transient arthropathy.

In patients with hemolytic anemia, parvovirus B19 supresses bone marrow erythropoietic activity, leading to transient aplastic crisis. Parvovirus B19 infections can also produce serious complications in patients who are immune compromised. People with defective cell mediated immunity (e.g., severe combined immunodeficiency syndrome; acquired immunodeficiency syndrome) can develop pure red cell aplasia, in which suppression of erythroid precursors is permanent. In utero exposure to parvovirus B19 occasionally produces a congenital anemia.

Table 2- Manifestations of Parvovirus B19 Infection in Chronic Host
Chronic Host Disease
Immunocompromised patient Pure red cell aplasia
Fetus Congenital anemia
Fetus Hydrops fetalis

Parvovirus B-19 is a member of the family of adenoviruses, and has a strong trophism for hematopoietic stem cells (2). The virus integrates into a specific site in the human genome. The infected cells fail to divide, impairing the production of new erythrocytes. Reticulocyte counts often fall to as low as 0.1% to 0.5% from the routine values of 6% to 20% in patients with hemolytic anemias.

Hemolytic anemias per se do not predispose patients to infection with parvovirus B19. The prevalence of antibody to the virus is equal in patients with hemolytic anemias and normal controls (3). In one study of patients with sickle cell disease who had transient aplastic crisis, 70% had prior parvovirus B19 infections (4). Normal children probably have an arrest of red cell production when infected with parvovirus B19. Since normal red cells are lost at a rate of only about 1% per day, a 5-day shut down would drop the hematocrit by about 5%, e.g. from a hematocrit of 38% down to 36%. This negligible change is clinically insignificant. In contrast, a person with sickle cell disease or thalassemia may turnover 10% of their red cells each day. A 5-day hiatus in red cell production could cause a hematocrit of 24% to fall to less than 12%. Anemia of this magnitude would be potentially fatal.

Parvovirus B19 has been cultured from the respiratory tract, and is presumed to be transmitted as an aerosol. The globoside gene product on erythroid cells, also known as the group P antigen, is the receptor for the virus (5). Rarely, the P antigen is completely absent on erythroid cells, which confers immunity to parvovirus B19 infection. Only one strain of the virus exists, so that immunity is lifelong following infection.

Table 3- Erythroid Group P Antigens
Phenotype Antigens present Prevalence 
European-Americans		 Prevalence 
African-Americans
P1 P1, P 80% 90-95%
P2 P 20% 5-10%
Pk2 k Very rare Very rare
Pk1 P1, Pk Very rare Very rare
p None 1:200,000 
(Amish; Swedish)		 Very rare

Laboratory Findings-
Reticulocytopenia is the sine que non of transient aplastic crisis. Bone marrow examination shows giant, multinucleated erythroblasts and pronormoblasts. Late normoblasts are almost completely absent. Pronormoblasts can show mild dysplastic changes. Parvovirus B19 infects mature erythroid progenitors (CFU-E), preventing further replication and maturation (6). The more primitive erythroid precursors (BFU-E) are affected minimally. Evidence exists that a non-structural gene product promotes apoptosis of the cells in the erythroid lineage.

In contrast to the erythroid series, the the numbers of granulocytic cells and megakaryocytes are normal (the M:E ratio is elevated, naturally, due to the paucity of normoblasts.) Consistent with this, peripheral blood polymorphonuclear leukocyte and platelet counts are normal.

Marked viremia can last for up to a week in patients with parvovirus B19 infection. Subsequently, the IgM antibody against the virus rises abruptly and peaks at 21 days. The IgG antibody to the virus then rises and remains elevated.

Diagnosis-
The diagnosis of transient aplastic crisis due to parvovirus B19 is often presumptive, based on a falling hemoglobin value and a low reticulocyte count in a patient with a hemolytic anemia. Specific DNA probes allow definitive diagnosis by PCR since the viremia is robust. A rising IgM antibody to the virus is another means of diagnosing parvovirus B19 infection.

Treatment-
Transient aplastic crisis usually is self-limiting and requires only supportive measures. Rare patients require more than a single transfusion to bridge the gap between marrow suppression and recovery. The fact that the BFU-E's are not suppressed by the virus means that the bone marrow is poised for a rapid response once the virus is tamed. Rare patients will need immunoglobulin treatment, which is dramatically effective in reversing the aplasia. Immunoglobulin concentrate is the treatment of choice and is delivered as 0.4 g/kg/day for 5 days.

Public Health-
Although viremia precedes the onset of Fifth disease and the associated transient aplastic crisis, viral titers are high even during the clinically manifest portion of the disorder. Consequently, precautions should be taken to avoid exposing other patients with hemolytic anemias or pregnant women to affected individuals. Physicians should warn patients and parents of patients with hemolytic disorders of the signs and symptoms of Fifth disease. Hospital personnel must be careful to avoid cross infection to other patients by those hospitalized with transient aplastic crisis (7). Although the disorder is endemic, epidemic outbreaks occur, during which people with hemolytic disorders must exercise even greater care. Since only one strain of the virus exists and the virus is extremely immunogenic, a vaccine to parvovirus B19 should be feasible. Early clinical trials of a prototype vaccine are underway. The absence of a known animal reservoir raises the possibility that parvovirus B19, like small pox, could be eradicated entirely.

Other Viruses

Other viral infections can also suppress hematopoiesis in patients with hemolytic disorders. Ordinary childhood infections such as Herpes zoster are often culprits. None show the selectivity seen with parvovirus B19 infection, however. Along with suppression of erythropoiesis, infections by these agents often impair granulocyte and/or platelet production. Hematological recovery usually parallels clinical recovery from the infection.

Vitamin Deficiency

The enhanced production of red cells associated with hemolytic anemias requires a large amount of folic acid. Folate deficiency in these patients can impair erythropoiesis with a consequent exacerbation of the anemia (8). While this complication is not common, most patients with hemolytic anemias are maintained with supplements of folic acid (9).

 

References

  1. Torok, TJ. 1992. Parvovirus B19 and human disease. Adv Int Med 37: 431-455.

  2. Kurtzman GJ, Gascon P, Caras M, Cohen B, Young, NS. 1988. B19 parvovirus replicates in circulating cells of acutely infected patients. Blood 71: 1448-1454.

  3. Teuscher T, Baillod B, Holzer BR. 1991. Prevalence of human parvovirus B19 in sickle cell disease and healthy controls. Trop Geogr Med 43:108-110.

  4. Rao SP, Miller ST, Cohen BJ.1992. Transient aplastic crisis in patients with sickle cell disease. B19 parvovirus studies during a 7-year period. Am J Dis Child 146: 1328-1330.

  5. Harris JW. 1992. Parvovirus B19 for the hematologist. Am J Hematol 39: 119-30.

  6. Takahashi T, Ozawa K, Takahashi K, Asano S, Takaku F. 190. Susceptibility of human erythropoietic cells to B19 parvovirus in vitro increases with differentiation. Blood 75 603-610.

  7. Bell LM, Naides SJ, Stoffman P, Hodinka RL, Plotkin SA. 1989. Human parvovirus B19 infection among hospital staff members after contact with infected patients. N Engl J Med 321: 485-491.

  8. Bills ND, Koury MJ, Clifford AJ, Dessypris EN. 1992. Ineffective hematopoiesis in folate-deficient mice. Blood 79: 2273-2280.

  9. Gray NT, Bartlett JM, Kolasa KM, Marcuard SP, Holbrook CT, Horner RD. Nutritional status and dietary intake of children with sickle cell anemia. Am J Pediatr Hematol-Oncol 14: 57-61


Home BWH MGH HMS