The Pediatric Infectious Disease Journal Volume 28, Number 7, July 2009

COINFECTION OF PARVOVIRUS B19 WITH OTHER

HEPATITIS VIRUSES LEADING TO FULMINANT
HEPATITIS OF UNFAVORABLE OUTCOME IN
CHILDREN
Mayank Dwivedi, MD,* Harmesh Manocha, MD,
Soumya Tiwari, MD, Gaurav Tripathi, MSc,
and T. N. Dhole, MD*
Abstract: Fulminant hepatic failure (FHF) associated with parvovirus B19
(B19) infection has a favorable prognosis in children. However, there is no
data available to predict outcome in cases of FHF associated with hepatotropic virus coinfection. Clinical characteristics of 3 pediatric groups
with FHF were compared and it was observed that B19 coinfection with
other viruses adds to the severity of the disease and increases the probability of a fatal outcome.
Key Words: parvovirus B19, fulminant hepatic failure, acute viral
hepatitis
Accepted for publication September 21, 2008.
From the *Department of Microbiology, Sanjay Gandhi Post Graduate Institute
of Medical Sciences, Lucknow, UP, India; Department of Microbiology,
Alluri Sitarama Raju Academy of Medical Sciences, Eluru, AP, India;
Department of Pediatrics, Lady Hardinge Medical College and Kalawati
Saran Children Hospital, New Delhi, India; and Department of Urology,
CSM Medical University, Lucknow, UP, India.
Address for correspondence: T. N. Dhole, MD, Department of Microbiology,
Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow
226014, India. E-mail: tndholesgpgi@gmail.com.

Supplemental digital content is available for this article. Direct URL

citations appear in the printed text and are provided in the HTML and PDF
versions of this article on the journals Web site (http://www.pidj.com).
DOI: 10.1097/INF.0b013e318198d05c

cute viral hepatitis caused by common hepatitis viruses A, B,

C, D, E, or other hepatotropic viruses including parvovirus
B19 accounts for 50% of cases of fulminant hepatic failure
(FHF) which has a mortality rate greater than 70%. Association
of parvovirus B19 (B19), with acute hepatitis and FHF is described by
several authors.1 4 This is associated with a favorable prognosis in
younger children.5 However, to the best of our knowledge, there is no
study available on prognosis of cases presenting with B19 coinfection
with other hepatotropic viruses.
The present study was designed to compare the clinical
characteristics and laboratory findings among 3 selected groups
presenting with FHF associated with: (i) B19 infection alone; (ii)
one or more other hepatotropic viral infection in the absence of
B19 infection; and (iii) B19 coinfection with other hepatotropic
viruses.

MATERIALS AND METHODS

The study was conducted in a large tertiary care referral
center of North India. Pediatric patients, 2 to 12 years of age,
admitted to our hospital from January 2003 to December 2007,
fulfilling the diagnostic criteria of FHF and laboratory evidence
of one or more common hepatotropic viral infection were
included in the study. The patients with drug-induced hepatitis,
cholestatic jaundice, congestive hepatopathy, and hepatitis resulting from multisystem failure were excluded from the study.
Clinical characteristics and results of laboratory investigation
previously conducted were recorded at the time of enrolment.
Serum samples and liver tissue specimen were obtained from all
the patients. All the serum samples as well as liver tissue
specimens were analyzed for the presence of B19 genome by
PCR based amplification followed by agarose gel electrophoresis. Serum samples were analyzed for the presence IgM anti 2009 Lippincott Williams & Wilkins

Parvovirus B19 and Hepatitis

bodies against specific viral antigens by ELISA (Ortho Clinical

Diagnostic ELISA Test system 3). We selected B19 genome as
viral marker for Parvovirus B19 and IgM antibodies against
specific viral antigens as viral markers for other hepatotropic
viruses. B19 DNA from serum samples was extracted using
from QIA amp DNA mini kit (QIAGEN, Germany) followed by
nested PCR as per Abe et al.6 Total RNA was extracted from the
liver tissues using Qiagen RNeasy kit (QIAGEN, Inc., CA)
according to manufacturers instructions. The purified RNA
obtained from liver tissues was further subjected to digestion by
RQI DNase (Promega Co., Madison, WI). The B19 cDNA was
synthesized from the pretreated RNA by reaction with 100 units
of Moloney murine leukemia virus reverse transcriptase (Fermentas, Germany) and B19 antisense primer. The cDNA obtained was subjected to nested PCR amplification. Serum samples and liver tissues were also obtained from 79 patients with
biliary atresia, and were used as controls for B19 genomic tests.
Informed consent for participation in this study was obtained
from the parents of each child. Institutes ethical committee
approved the work and all parents of all individuals included in
the study consented for enrollment.
Statistical calculations were done by Fisher exact test and 2
test taking P 0.05 as significant. Odds ratios (OR) with a 95%
confidence interval limit were calculated from 2 2 contingency
table.

RESULTS
In the initial phase a total of 48 patients with FHF were
included in the study. One or more viral markers were detected in
26 patients either in the serum samples or liver tissue. Of 48
patients B19 genome was present in 19 (39%), of which 13 (27%)
were also positive for IgM antibodies against one or more other
hepatotropic viruses (HAV in 3 patients, HBV in 6 patients, HCV
in 2 patients, and HAV plus HEV in 2 patients). In patients
negative for B19 genome (n 29), 7 (15%) patients showed the
presence of IgM antibodies against one hepatotropic virus each
(HBV in 3; HCV in 2; and HAV and HEV in one patient each).
Among biliary atresia cases B19 genome (DNA) was detected in
11 of 79 cases. PCR-positivity in FHF cases was significantly
higher (P 0.0022) and the risk was increased 4-fold (OR
4.05; 95% CI 1.719.58).
B19 mRNA was detected in 19 (39%) of 48 liver tissue
specimens from FHF cases. Presence of B19 mRNA in the liver
tissue correlated with the presence of B19 genome in the serum
samples. Among the biliary atresia cases B19 mRNA was
present in only 8 of 79 (10.1%). Association of B19 mRNA and
FHF cases differed significantly with that of biliary atresia
cases (P 0.0002) and the risk was found to be 6-fold
(OR 5.82; 95% CI 2.29 14.77).
Clinical characteristics and laboratory findings of patients in
the 3 groups were compared. The groups were found age matched.
The main distinctive features of parvovirus B19 and other hepatitis
viruses coinfection associated FHF were: presence of jaundice,
high bilirubin, high alanine aminotransferase or aspartate aminotransferase activity, and unfavorable outcome resulting in death of
most of the patients (Table, Supplemental Digital Content 1,
http://links.lww.com/A1140). Results of statistical analyses are
summarized in the Table 1.

DISCUSSION
Association of fulminant or acute hepatitis with B19 infection has been previously reported.4,5 The causal association of B19
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The Pediatric Infectious Disease Journal Volume 28, Number 7, July 2009

Vaillant et al

TABLE 1. Comparison of Clinical Characteristics and Outcomes of Patients Having

Fulminant Hepatitis Associated With Parvovirus B19 Alone, Parvovirus B19 Coinfection, and
Other Hepatitis Viruses

Clinical characteristics
Fever-present
Fever-absent
Rash-present
Rash-absent
Jaundice-present
Jaundiceabsent
Outcome
Alive
Dead

B-19 Alone
(n 6)

B19 Coinfection With Hepatitis

(A, B, C, and/or E) Viruses
(n 13)

Other Hepatitis Viruses

(Hepatitis A, B, C, or E)
(n 7)

2
4
2
4
1
5

5
8
2
11
11
2

3
4
0
7
4
3

0.94

6
0

3
10

3
4

0.0074*

0.2519
0.0175*

*Significant value (P 0.05).

with FHF was demonstrated by Abe et al6 who isolated and

characterized erythrovirus B19 genomes from liver tissues of
patients with FHF.
Although hepatitis has been attributed to B19 infection
by several other groups of investigators,1 4 the presence of B19
genome in liver tissues has not been proved to be specific for
acute infection as it is found in liver tissue of patients with FHF
and in control patients.2 Because viral genome can persist in
tissues, viremia could be a more specific marker of an acute
infection.7,8 Moreover, B19 hepatitis results in high levels of
viremia, usually 1010 virions/mL (our experience). The diagnosis of B19 infection was established by PCR based detection of
its genome. In our study B19 DNA was detected in 19 of 48
patients having FHF, which is consistent with the findings of
Langnas et al2 and Abe et al,6 though the prevalence of B19 is
higher among our patients.
Abe et al6 have detected B19 genome in liver of the patients
who were serologically negative for the viral genome. In their
study, only one serum sample was found positive for the B19
genome among 8 cases with intrahepatic-B19 DNA. These results
suggest that absence of B19 sequence in serum does not rule out
the existence of current infection by B19 within the liver. On the
other hand, Eis-Hubinger et al9 showed that direct detection of
viral genomes in liver tissues by a highly sensitive method is as
important as serology.
In the present study, the presence of B19 mRNA in the liver
tissue was analyzed to detect viral replication. In all of the serum
B19-positive cases, B19 mRNA was present in the liver tissue
indicating presence of viral replication in all cases with fulminant
hepatitis. By contrast, in only a small percentage of cases with
biliary atresia (8/79) B19 replication was detected in liver tissues.
A significantly high prevalence of B19 infection was found in
fulminant hepatitis patients. Low rate of B19 infection has been
observed in biliary atresia cases as determined by B19 DNA (in
serum) and B19 mRNA (in liver tissues). Similar association has
also been observed by a few authors,6 but the exact relationship of
B19 and biliary atresia is unknown.
The disease severity was significantly greater in patients
with B19 coinfection. There is a possibility that B19 causes injury
to hepatocytes independently and produces synergistic effect when
present along with other hepatitis viruses as a cofactor (like
Hepatitis D). In conclusion, pediatric patients with FHF had high
prevalence of B19 associated with other hepatitis viruses coinfection, had relatively severe disease and poor outcome.

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REFERENCES
1. Yoto Y, Kudoh T, Haseyama K, et al. Human parvovirus B19 infection
associated with acute hepatitis. Lancet. 1996;347:868869.
2. Langnas AN, Markin RS, Cattral MS, et al. Parvovirus B19 as a possible
causative agent of fulminant liver failure and associated aplastic anemia.
Hepatology. 1995;22:16611665.
3. Pardi DS, Romero Y, Mertz LE, et al. Hepatitis-associated aplastic anemia
and acute parvovirus B19 infection: a report of two cases and a review of
the literature. Am J Gastroenterol. 1998;93:468 470.
4. Bernuau J, Durand F, Valla D. Parvovirus B19 infection and fulminant
hepatitis. Lancet. 1999;353:754 755.
5. Sokal EM, Melchior M, Cornu C, et al. Acute parvovirus B19 infection
associated with fulminant hepatitis of favorable prognosis in young children. Lancet. 1998;352:1739 1741.
6. Abe K, Kiuchi T, Tanaka K, et al. Characterization of erythrovirus B19
genomes isolated in liver tissues from patients with fulminant hepatitis and
biliary atresia who underwent liver transplantation. Int J Med Sci. 2007;4:
105109.
7. Soderlund M, von Essen R, Haapasaari J, et al. Persistence of parvovirus
B19 DNA in synovial membranes of young patients with and without
chronic arthropathy. Lancet. 1997;349:10631065.
8. Clewley J. PCR Detection of Parvovirus B19. Washington, DC: American
Society for Microbiology; 1993.
9. Eis-Hubinger AM, Reber U, Abdul-Nour T, et al. Evidence for persistence of
parvovirus B19 DNA in livers of adults. J Medical Virol. 2001;65:395401.
10. OGrady JG. Acute liver failure. Postgrad Med J. 2005;81:148 154.

UNDERCOOKED GROUND BEEF AND PERSON-TOPERSON TRANSMISSION AS MAJOR RISK

FACTORS FOR SPORADIC HEMOLYTIC UREMIC
SYNDROME RELATED TO SHIGA-TOXIN
PRODUCING ESCHERCHIA COLI INFECTIONS IN
CHILDREN IN FRANCE
Veronique Vaillant, MD, MPH,* Emmanuelle Espie, DVM, MPH,*
Henriette de Valk, MD, MPH,* Ulrike Durr, MPH,*
Delphine Barataud, MPH,* Philippe Bouvet, PhD,
Francine Grimont, PharmD, PhD,
and Jean-Claude Desenclos, MD, PhD*
Abstract: In a prospective matched case-control study of sporadic pediatric
hemolytic uremic syndrome related to Shiga-toxin producing Escherichia coli
infection in France, eating undercooked ground beef, contact with a person
with diarrhea, and drinking well water during the summer period were
identified as risk factors. Prevention efforts in France should focus on reducing
not only food-borne but also person-to-person transmission.

2009 Lippincott Williams & Wilkins