Parvovirus B19-associated erythropoiesis-stimulating agent hyporesponsiveness in a patient on maintenance hemodialysis: A case report.

Parvovirus B19 is an uncommon cause of hypoproliferative anemia. In maintenance hemodialysis (HD), anemia is rarely explained by a single mechanism, and the viral suppression of erythropoiesis may be overlooked when infection, inflammation and iron deficiency occur concomitantly. The present case report describes the case of a 79-year-old man receiving chronic HD who was admitted twice with prolonged fever and was eventually treated for culture-negative mitral valve endocarditis. During the second hospitalization period, the hemoglobin level decreased from 8.8 to 7.7 g/dl, despite an increase in the level of recombinant human erythropoietin (rHuEPO) from 30,000 to 60,000 IU/week. The number of reticulocytes decreased from 2.07 to 0.95%, and a blood transfusion was required. The patient tested positive for Parvovirus B19 immunoglobulin M and immunoglobulin G, and polymerase chain reaction (PCR) confirmed active infection. Bleeding, hemolysis, vitamin B12 and folate deficiency, uncontrolled hypothyroidism, malignancy and inadequate dialysis were excluded. Intravenous immunoglobulin was administered at 0.4 g/kg/day for 5 days. By the time of discharge, the hemoglobin level had increased to 9.4 g/dl and reticulocytes had increased to 2.7%. Repeat PCR at follow-up, 20 days following discharge, yielded negative results. Severe iron deficiency was then evident, and following the administration of ferric carboxymaltose, the hemoglobin level further increased to 12.1 g/dl, allowing a reduction in rHuEPO. On the whole, the present case report underlines that Parvovirus B19, although rare, should remain in the differential diagnosis of erythropoiesis-stimulating agent-resistant anemia in patients undergoing HD.