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An unusual cause of cerebellar ataxia in an immunocompromised elderly patient

https://doi.org/10.1016/j.jns.2014.02.023Get rights and content

Highlights

  • PVB19 infection should be in the differential diagnosis of cerebellar ataxia in immunocompromised patients.

  • Spinal fluid analysis in CNS PVB19 can be unremarkable.

  • Benefit of IVIG therapy in cases of PVB19 infection needs to be further studied.

Abstract

Background

Parvovirus B19 is a single-stranded DNA virus belonging to the family Parvoviridae, genus Erythrovirus. PVB19 infection is most common in the pediatric population, manifesting as erythema infectiosum. In patients with hemoglobinopathy, PVB19 infection is known to cause aplastic anemia. PVB19 infection rarely affects the nervous system — reported manifestations include seizures, encephalitis and meningoencephalitis. Less common presentations include stroke, cerebellar ataxia, optic neuritis, brachial plexitis, Guillain–Barré syndrome and carpal tunnel syndrome.

Methods

Review the different central nervous system (CNS) manifestations and treatment strategies in all reported cases of adult CNS PVB19 infection.

Results

Cerebellar ataxia is a very rare manifestation of PVB19 CNS infection. Our patient had refractory chronic lymphocytic leukemia and PVB19 in bone marrow and serum; he presented with 6-week history of progressive pan-cerebellar ataxia. CSF was acellular but PVB19 was present on PCR test. Early treatment with intravenous immunoglobulin (IVIG) led to improvement in the patient's neurological deficits.

Conclusions

PVB19 CNS infection should be in the differential as a cause of cerebellar ataxia in immunocompromised patients. Recognition is critical to early institution of appropriate therapy. Our patient showed considerable improvement in ataxia after IVIG therapy.

Introduction

Parvovirus B19 (PVB19) belongs to family Parvoviridae, genus Erythrovirus. It is a single-stranded DNA virus that manifests most frequently as erythema infectiosum and aplastic anemia in children and patients with hemoglobinopathies. In immunocompromised patients PVB19 can present with pure red cell aplasia. Common neurological manifestations of PVB19 infection include seizures, encephalitis and meningoencephalitis; less common are stroke, cerebellar ataxia, optic neuritis, brachial plexitis, Guillain–Barré syndrome and carpal tunnel syndrome. We report a case of cerebellar ataxia in an immunocompromised elderly man [1], [2].

Section snippets

Case report

A 70-year-old man with relapsed and refractory CLL, treated with 29 cycles of revlimid plus ofatumumab, recently transitioned to single-agent revlimid, presented with a 6-week history of unsteady gait, slurred speech and tremors in his hands. He noticed progression of symptoms one week before admission. Review of systems was positive for episodes of choking with liquids and lightheadedness. Two months before presentation, chemotherapy was held due to development of pure red cell aplasia. He

Discussion

PVB19 infection can present with a wide spectrum of symptoms. It can range from self-limiting minor constitutional symptoms to disabling CNS and/or peripheral nervous system (PNS) involvement. Douvoyiannis et al. [1] reviewed 81 cases of neurologic manifestations of PVB19 infection in the adult and pediatric population. Overall, CNS and PNS involvement was seen in 77% of adult and 23% of pediatric patients with PVB19 infection. Some of the CNS manifestations in order of frequency are

Disclosure

The authors report no disclosure.

This study does not involve use of any grant funds.

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