SPONTANEOUS ATRAUMATIC SPLENIC RUPTURE FOLLOWING INTRAVENOUS IMMUNOGLOBULIN FOR PARVOVIRUS B19 ASSOCIATED PURE RED CELL APLASIA IN A RENAL TRANSPLANT PATIENT – A CASE REPORT

M TIONG1, H NANDURKAR1,2, R WALKER1,2, S WILSON1,2,3

1Alfred Health, Melbourne, Victoria; 2Monash University, Melbourne, Victoria; 3Baker IDI, Melbourne, Victoria

Introduction: Parvovirus B19 (PB19) infection is an uncommon cause of anaemia in solid organ transplant. Persistent cases may be treated with intravenous immunoglobulin (IVIg). We report a case of PB19 associated anaemia in a renal transplant recipient who subsequently developed an atraumatic splenic rupture after administration of IVIg.

Case presentation: A 58 year-old male received his second renal transplant in August 2016 (first transplant in 1985 for chronic glomerulonephritis). He developed progressive anaemia from 6-months post transplant (haemoglobin nadir 57 g/L) requiring transfusion support. Further investigation demonstrated a suppressed reticulocytosis with preserved platelet, myeloid and lymphoid lines, consistent with pure red cell aplasia (PRCA). Plasma PB19 IgM was equivocal with negative IgG serology. Subsequent qualitative PB19 DNA PCR was positive.  Bone marrow biopsy showed features consistent with PB19 associated PRCA.

The patient remained anaemic and subsequently progressed to IVIg infusion (2g/kg in two divided doses, 3 days apart). Following treatment there was recovery of reticulocyte counts with spontaneous increment in haemoglobin levels. Repeat serum PB19 PCR was negative.

The patient re-presented 1-week after IVIg with sudden onset abdominal pain. CT demonstrated spontaneous splenic haemorrhage with evidence of an underlying splenic haemangioma.

Though described, spontaneous atraumatic rupture of splenic haemangioma is quite unusual, with PB19 virus a particularly unusual infective cause. Whilst it is possible that rapid erythrocytosis and splenic erythrocyte aggregation may have contributed to his presentation, IVIg administration itself may trigger splenic sequestration of red-cells and has been associated with spleen rupture in primary cytomegalovirus (but not PB19) infections.

Conclusions: To our knowledge this is the first reported case of spontaneous atraumatic splenic rupture following administration of IVIg for treatment of PB19 associated PRCA.

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