Human parvovirus B19 (erythrovirus) infection in pregnancy

Susanne Modrow Institut fr Medizinische Mikrobiologie Universitt Regensburg

Common Features of Parvoviruses Small icosaedral non-enveloped (naked) particles ( 20-24 nm), consisting of two capsidproteins (VP1 und VP2) High stability against detergents and environmental influences Limited numbers of serotypes Phospholipase A2-like enzyme activity present in the VP1-unique region, necessary for virus infectivity

Common Features of Parvoviruses Viral genome: single stranded DNA (5000 5500 bases) Genetic coding capacity: low 2 capsid proteins (VP1 and VP2) 2 3 non-structural proteins (rep1, rep2, NS1, NP1, 11kDa, 7.5kDa) limited mubers of genotypic variants

Sequence variability:

Phospholipase A2-like enzyme activity exerted by the VP1-unique region is necessary for virus infectivity

Phylogenetic analysis of parvovirus B19 genotypes 1-3

Low prevalence in acute infection (Europe, America, Africa) Frequently isolated from tissue of older individuals (> 60 years) Low prevalence in acute infection (France, South/West Africa, South America)

Most frequent in acute infection (worldwide) Frequently isolated from tissue of younger individuals (< 50 years)

Parvovirus B19 Seroprevalence (Germany)

Age: Children, 4-6 years: Children, 6-10 years: Young adults, 25-29 years: Adults, 65-69 years: Gender Women (18-79 years): Men (18-79 years): Women (18-49 years): 73,4 % 70,8 % 72,4 % 35 % 50 % 70 % 79 %

Acute parvovirus B19 infection - symptoms

The majority of parvovirus B19 infections in immunocompetent individuals is associated with mild symptoms General feelling of illness, anaemia Erythema infectiosum, fifth disease Transient arthritis Risk groups which may develop severe symptoms A. Pregnant women: Abortion Hydrops fetalis Fetal death B. Individuals with disorders associated with shortened red cell survival (sickle cell anemia, thalassemia, hereditary spherocytosis, blood loss etc Transient aplastic crisis C. Individuals with predisposition for the development autoimmune disease or suffering from autoimmune disease Initial estabishment of autoimmune disease Severe flare of autoimmune disease D. Immunosuppressed patients (transplant recipients, tumor-, HIV-patients, etc): Chronic anemia, thrombocytopenia, pancytopenia

Parvovirus B19 - Pregnancy

A. Spontaneous abortion

Risk period: Acute infections during first trimester. Spontaneous abortions mainly occur between weeks 1-16 (20) of gestation Frequency: Rate of spontaneous abortion is elevated by 5,6% in pregnant women with acute parvovirus B19 infection (Enders et al., 2004) Cause: Thrombocytopenia ? Vasculitis in placental tissue? Transmission and infection of the fetus ? (starting from week 12 of gestation)

Parvovirus B19 - Pregnancy

B. Hydrops fetalis Risk period: Acute infections occurring during the first 20 weeks of gestation. (Enders et al., 2004; Miller et al., 1998; Yaegashi et al., 1999) The fetus develops hydrops fetalis between weeks 14-28 of gestation. The fetus develops hydrops fetalis 2-8 (18-20) weeks after the infection of the pregnant woman. Frequency: 3,9% (Enders et al., 2004) to 10% (Yaegashi et al., 1994) of acute parvovirus B19 infections result in the development of non-immune hydrops fetalis Outcome: Spontaneous recovery without therapy (mild course): 30% Severe course: 70% Therapy (intrauterine transfusion): 80 % successful Fetal death: 20%

Parvovirus B19 - Pregnancy

B. Hydrops fetalis Cause: Viral transmission to the fetus (starting from week 12 of gestation) Infection of and viral replication in fetal erythroid precursor cells in the fetal liver (hepatic stage of haematopoiesis, short red cell half life) Destruction of erythroid precursor cells, Stopp of fetal erythropoiesis, aplastic crisis edema in fetal tissue due to alterations in fetal blod circulation, heart failure Infection and viral replication of fetal myocard may result in myocarditis

Parvovirus B19 - Pregnancy

C. Intrauterine fetal death (IUFD) late pregnancy (third trimester)
Risk period: Unclear IUDF occurs after week 28 of gestation, IUDF may occur more than 5 months after acute parvovirus B19 infection of pregnant women but also in the abensce of acute infection Frequency: Parvovirus B19 DNA was detectable in 7/93 (7.5 %) of nonhydropic fetuses with IUFDs (Skjldebrand-Sparre et al., 2000) Parvovirus B19 DNA was detectable in 7/47 (15 %) of nonhydropic fetuses with IUFDs (Tolfvenstam et al., 2001) Parvovirus B19 DNA was detectable in 13/92 (14 %) of nonhydropic fetuses with IUFDs (Norbeck et al., 2002) Parvovirus B19 DNA was detectable in 4/169 (2.4 %) of nonhydropic fetuses with IUFDs (Riipinen et al., 2008) Cause: Unclear

Management of acute parvovirus B19 infection during pregnancy (week 1 to 20/22 of gestation)
1. Serodiagnosis of acute parvovirus B19 infection a) Seroconversion b) Detection of B19V-DNA by PCR 2. Starting from week 14 of gestation: Doppler ultrasound monitoring (MCA-PSV) of fetal anaemia in intervals of 1 2 weeks for at least 12 weeks after maternal infection 3. Treatment of fetal anaemia (Hb below 8 g/dl) : Intrauterine transfusion of packed erythrocytes Successful in ca. 80 % of cases 4. Embryopathies have not been reported.

Acute parvovirus B19 infection

IgG against linear epitopes in VP2

Acute parvovirus B19 infection in pregnant women problems

1. In most cases, the exact time point of B19V-infection (contact to an infected individual) is unclear, particularly during epidemic outbreaks. 2. Acute parvovirus B19 infection may be asymptomatic or associated with diffuse symptoms. 3. There is no correlation between the extent of viraemia and the development of hydrops fetalis. 4. The development of hydrops fetalis usually occurs during a period of 4 to 6 weeks following maternal infection. Up to 20 weeks have been reported to occur between acute B19Vinfection of pregnant women and the development of hydrops fetalis. Ultrasound monotoring has to be continued.

Acute parvovirus B19 infection in pregnant women problems

5.

B19V-specific IgM-antibodies (anti-VP1/VP2-IgM) are present only transiently or may become undetectable in the presence of viraemia (formation of immunocomplexes). If the serostatus of the pregnant woman is unknown and back-up (booking) samples derived from previous periods are not available, acute infection has to be excluded by analysis of B19V-DNA by PCR

False-negative serology is frequent in acute parvovirus B19 infection

118 plasma and serum samples were analysed by qPCR for the presence of parvovirus B19-DNA and for VP1/VP2-specific IgG and IgM by ELISA All samples had been sent to the diagnostic department for detection of B19V-DNA All samples were derived form immunocompetent individuals. Overall result 83/118 (70,1%) samples displayed viremia; 35 (28,9%) were B19V-DNA negative

Analysis of serum and plasma samples for B19V-DNA and B19V-specific antibodies

Samples (No.)

B19V-DNA [geq/ml] Range Mean 1.7x1011 2.7x106 2.4x104

VP1/VP2-specific antibodies IgG-/IgM18 (90%) 4 (16%) 2 (5.2%) IgG+/IgM0 (0%) 0 (0%) 7 (18.4%) IgG-/IgM+ 2 (10%) 4 (16%) 1 (2.6%) IgG+/IgM+ 0 (0%) 17 (68%) 28 (73.7%)

20 25 38 83 (Total)

1.5x108 1.7x1012 1.1x105 2.5x107 1.0x103 8.0x104

1.0x103 1.7x1012

5.7x1010

24 (28.9%)

7 (8.4%)

7 (8.4%)

45 (54.2%)

31/83 (37.3%) samples were VP1/VP2 IgM negative

Analysis of 118 serum and plasma samples by quantitative PCR for the presence of B19V-DNA and for VP1/VP2 specific IgG and IgM by ELISA. 300
B19V VP1/VP2-specific IgG/IgM [U/ml]

200

100

0 IgG IgM IgG IgM IgG IgM IgG IgM IgG IgM

B19V DNA [geq/ml] Number of samples

> 108

107 - 105

<104

seropositive seronegative 20 25 38 30 5

Analysis of serum samples derived form pregnant women with reported B19V-contact for B19V-DNA and B19V-specific antibodies

Patient

Week of gestation 21 22 23 26 32 8 15 6 11 16 5

B19V-specific IgG + + ++ ++ +++ +++ ++ ++ ++ +++ IgM ++ + + + -

B19V-DNA load (geq/ml) 6.2 x 102 3.6 x 1012 6.3 x 105 1.3 x 104 102 - 103 6.3 x 108 n.d. 6.9 x 104 2.5 x 102 1.0 x 104 2.3 x 103

1 Age: 32 years

2 Age: 34 years 3 Age: 32 years 4 Age: 27 years

Parvovirus B19 infection in pregnant women special features 1.

Following acute B19V-infection pregnant women may establish persisting low-level viraemia lasting for several months

2. In late pregnancy, seropositive pregnant women (past B19V-infection) may display low-level viremia, possibly due to reactivation of latent viral genomes present in tissue.

Parvovirus B19 reactivation in pregnant women special features Prospective study: 26 pregnant women, consecutive blood samples obtained at weeks of gestation 9-11 (time point I) weeks of gestation 24-26 (time point II) weeks of gestation 33-35 (time point III) weeks 2-3 after delivery (time point IV) Analysis of: B19V-DNA VP1/VP2-specific IgG and IgM, VP2- and NS1-specific cellular immune responses seronegative: seroconversion: seropositive: 7 women (all B19V-DNA negative) 2 women between time points (II) and (III) 1: one B19V-DNA positive, 103 geq/ml 17 women 8 women: B19V-DNA negative 9 women: B19V-DNA positive (102103 geq/ml) at time points (III) and/or (IV)

Overall result:

Example 1
250 200 150 100 50 0 time point I time point II IgG

B19V-DNA

Declining VP1/VP2-specific IgG Increasing VP1/VP2-specific IgM

time point III IgM time point IV

102-103 geq/ml B19B-DNA

Example 2
140 120 100 80 60 40 20 0 time point I time point II IgG

B19V-DNA

time point III IgM

time point IV

Parvovirus B19 reactivation in pregnant women special features Conclusions 1. Seropositive pregnant women may develop transient low-level B19V viraemia in late pregancy /delivery. 2. In none of these cases B19V-associated fetal or maternal complications were observed, all were asymptomatic. 3. Low-level viraemia in late pregnancy may be due to reactivation of latent B19V-genomes present in tissue

Co-workers, co-operateurs, aides and friends

Today in Regensburg: Dr. Simon Bredl Dr. Annelie Plentz Dr. Jrgen Wenzel med. cand. Robert Heyd .........and in the rest of the world ... Prof. Dr. Barbara Grtner, Virologie, Universitt des Saarlands Prof. Dr. Birgit Seelbach-Gbel, Frauenklinik St..Hedwig, Regensburg Dr. Johannes Mst, Mikrobiologisches Labor Innsbruck Prof. Dr. Hartwig Lehmann, Pdiatrie, Universitt Gieen Prof. Dr. Anna-Maria Eis-Hbinger, Mikrobiologie und Immunologie, Bonn Prof. Dr. Klaus Hedman, Institut fr Virologie, Universitt Helsinki Dr. Brbel Kaufmann, Purdue University, West Lafayette Yesterday in Regensburg: Dr. Juha Lindner Dr. Ulla Raab Dr. Antje Knll Dr. Sven Schimanski