P2.M253: Septic Shock and Pancytopenia Associated with Parvovirus B19

Introduction: Human Parvovirus B19 (PB19) is a single-stranded DNA virus. Certain risk factors including pregnancy, blood disorders, and immunosuppression can increase risk of significant complications from PB19. Septic shock and pancytopenia are two potential life-threatening complications, but are extremely uncommon, especially in otherwise healthy people. We report a pediatric case of septic shock and pancytopenia associated with a PB19 infection in a previously healthy patient.

Case Description: A 6-year-old female with no significant past medical history was admitted to the PICU after initially presenting to an outlying ED with rash, fever, fatigue, and swollen hands/knees for six days. She had hypotension in the 80s/30s despite multiple fluid boluses, norepinephrine drip, and antibiotics prompting transfer to our PICU with worsening septic shock and possible bacterial meningitis.

Upon arrival, she had generalized pain, petechial rash, ecchymosis, edema with refractory septic shock, generalized anasarca, DIC, bandemia, pancytopenia, hypomagnesemia, hypoalbuminemia, hypophosphatemia, elevated inflammatory markers, and acute hypoxic respiratory failure requiring intubation.

LP showed no evidence of meningitis. Antibiotics, IVF, inotropic medications, FFP, and platelet transfusions were administered. Imaging showed mild hepatosplenomegaly/ascites. Differential included autoimmune disorders, infectious organism, and rare conditions like Multisystem Inflammatory Syndrome in Children (MISC) and Hemophagocytic lymphohistiocytosis (HLH). Infectious disease, Hematology/Oncology and Allergy/Immunology specialists were consulted prompting further work-up for HLH and other infectious etiologies.

Comprehensive immunodeficiency work-up including ANA, rheumatoid factor, immunoglobulin levels, and serum CXCL9 were unremarkable. Blood, urine, and CSF cultures showed no growth. Subsequent labs were negative for tickborne disease and immunodeficiency, and positive for SARS-COVID 2 antibodies and PB19 PCR. CXR revealed pleural effusion, treated with furosemide. IV hydrocortisone was given for low cortisol. MRI brain performed for acute mental status change resulted normal. IVIG 2g/kg was given on day 3 with improvement in symptoms, and resolution of pancytopenia. Patient was extubated on day 5 and transferred to the general floor. PB19 IgM and IgG antibodies were elevated indicating acute infection, while ASO titers and antibodies for CMV, EBV, and HHV-6 were negative. The positive PB19 PCR with elevated IgG/IgM along with lab results and presentation made PB19 viral sepsis the most likely diagnosis.

Discussion: This case illustrates a distinctive presentation of septic shock and pancytopenia in PB19 infection, diverging from conventional clinical patterns. Notably, it draws attention to the similarities between PB19 viral sepsis and HLH, characterized by fever, cytopenia, elevated ferritin levels, and neurological symptoms. These parallels underscore the importance of considering PB19-induced septic shock in the differential diagnosis, particularly when confronted with patients exhibiting unconventional presentations.

Conclusion: Clinicians should be aware of the existence of parvovirus-induced septic shock and pancytopenia, ensuring it remains within their differential when evaluating patients presenting with these atypical manifestations. Recognizing these potential complications early can facilitate prompt intervention and improve patient outcomes.