1 Pathology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42122 Reggio Emilia, Italy.
2 Hematology Unit, CREO, Azienda Ospedaliera di Perugia, University of Perugia, 06123 Perugia, Italy.
3 Pathology Unit, Azienda Ospedaliero-Universitaria-Ospedali Riuniti di Foggia, 71122 Foggia, Italy.
4 Surgical Oncology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42122 Reggio Emilia, Italy.
5 Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, 41121 Modena, Italy.
6 Oncohematology Unit, Azienda Ospedaliera S. Maria di Terni, University of Perugia, 05100 Terni, Italy.
7 Pathology Unit, Azienda Ospedaliera S. Maria di Terni, University of Perugia, 05100 Terni, Italy.
Received: January 30, 2021
Accepted: February 14, 2021
Mediterr J Hematol Infect Dis 2021, 13(1): e2021026 DOI 10.4084/MJHID.2021.026
| This is an Open Access article distributed
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To the editor.
We report the case of a 50-year-old woman with a few years history of common variable immunodeficiency (CVID), presenting with profound asthenia. The patient had previously declined immunoglobulin therapy due to the absence of infective episodes. Few days before admission, she had a fever following the meningococcal vaccine. On admission, the patient was afebrile. Splenomegaly (16 cm in maximum diameter) was present in the absence of lymphadenopathy. Laboratory tests revealed anemia (Hb 7.5 g/dl) with low reticulocyte count (0.1%, normal adult range 0.5% to 2.5%). Serum electrophoresis confirmed hypogammaglobulinemia (IgG 519 mg/dl, normal range 700-1600 mg/dl; IgA 46 mg/dl, normal range 70-400; IgM 20 mg/dl, normal range 40-280 mg/dl). Lactate dehydrogenase (LDH) level was elevated (594 UI/L). Coombs test was negative. B12 vitamin and folate were within normal values. Serologic tests for Hepatitis B and Hepatitis C virus, Human Immunodeficiency Virus (HIV), and Parvovirus B19 were negative, as well as rheumatoid factor and antinuclear antibodies.
Bone marrow biopsy showed a normocellular marrow with a reduced erythroid lineage relative to the overall intact granulopoiesis. The erythropoiesis was almost completely made up of large-sized proerithroblasts (so-called megaloblasts) with vesicular chromatin and a subtle nuclear membrane (Figure 1). Megakaryocytes were slightly increased in number with nuclear lobulation defects. Cytogenetic analysis revealed a normal karyotype. Bone marrow aspirate confirmed the presence of giant proerythroblasts with cytoplasmic vacuoles (Figure 2). The marrow findings were suggestive of Parvovirus B19 infection. In our patient, Parvovirus B19 serology was negative. However, polymerase chain reaction (PCR) detected Parvovirus B19 DNA (556,936 viral copies) on peripheral blood. Prompt treatment with intravenous immunoglobulins (400/mg/kg for five days) was started with progressive anemia resolution and a marked decrease of viral DNA copies. Because of the infective episode, treatment with subcutaneous immunoglobulins was continued indefinitely. The patient is well, with no other infective episode at about three years from Parvovirus B19 infection.
|Figure 1. Bone marrow biopsy showing large proerytroblasts with dispersed chromatin and subtle nuclear membrane (HE x400 magnification).|
|Figure 2. Bone marrow aspirate highlighting giant proerythroblasts with cytoplasmic vacuoles.|
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