Parvovirus b19-Induced Acute Hepatitis With Hepatosplenomegaly and Polyarthropathy

Parvovirus B19 infection can present with myriads of clinical diseases and syndromes; hepatitis and polyarthropathy are a few of these examples. Parvovirus frequently affects children but this condition has also been reported in adults. The present case report discusses a case of a 43-year-old female who presented to the outpatient department (OPD) with complaints of high-grade fever and pain in multiple joints of her body for three days. On examination, stiffness and swelling of the hand, knees, wrist, and ankles were noted. Laboratory investigations showed highly elevated aspartate transaminase (AST), alanine transaminase (ALT), and bilirubin. Electrocardiogram (ECG) and echocardiogram (ECHO) findings were unremarkable. PCR testing showed the presence of parvovirus. Parvovirus B19 infection led to the development of acute hepatitis, which appeared as yellowing of skin (jaundice) and led to hepatosplenomegaly. Parvovirus-induced polyarthropathy was also observed in the patient. The patient was managed with a parenteral course of ceftriaxone, paracetamol, and a normal saline infusion. Anti-viral drugs were also prescribed to the patient including ribavirin and pegylated interferon. This case study will explore how the patient was diagnosed and managed with conventional therapy and anti-viral to relieve parvovirus-induced hepatitis with hepatosplenomegaly and polyarthritis. Acute hepatitis can be caused by viruses and other noninfectious causes, all of which must be cleared out to avoid chronic disease development. When patients present with joint pain and skin rashes, a thorough workup for viral indicators, medication histories, autoimmune and metabolic illnesses, and parvovirus b19 infection is required.


Introduction
Parvoviruses are the smallest of deoxyribonucleic acid (DNA) viruses belonging to the Parvoviridae family, and human parvovirus b19 is the only parvovirus known to be pathogenic for humans [1]. Parvovirus b19 infection leads to a wide variety of symptoms in children as well as adults. Fever, headache, erythema infectiosum, and anemia are commonly observed symptoms in children while adults commonly suffer from multiple-joint pain and inflammation as well as generalized body aches. Thrombocytopenia and neutropenia are less commonly observed [2]. Our case represents a patient who developed polyarthropathy, rashes, and some rarely observed symptoms like acute hepatitis, which subsequently led to hepatosplenomegaly.

Case Presentation
A 43-year-old female presented to the outpatient department (OPD) with complaints of high-grade fever and pain in multiple joints of her body for three days. The patient was feeling pain in her wrists, hands, ankles, and knees. Initially, the pain was mild, and there were no associated symptoms. Three days later, the same patient came to OPD again with a complaint of the development of a rash on her both lower limbs. The rash only appeared just above both ankles up to the mid legs. This time patient was feeling excruciating pain in her multiple joints.
Besides rash and severe pain, the patient also complained about abdominal pain with nausea, anorexia, and mild discomfort. And she noticed yellow discoloration of skin (jaundice) 24 hours prior to the consultation, which was later confirmed by high level of bilirubin mentioned in Table 1. There were no other complains about any muscle pain, body pain, back pain, chest pain, cough, or breathing difficulties. Her vision was perfectly fine. There was no associated history of traveling or gastrointestinal/genitourinary infection. The patient denied alcohol and any intravenous drug intake. Detailed findings on examinations are mentioned in

Investigations
Lab investigations were ordered to confirm the diagnosis. CBC report is given in Table 3.  Blood culture was negative, and urine and stool cultures were found unremarkable. ECG and ECHO findings were normal. Similarly, on X-rays of hands, ankles, and feet no joint erosion was observed. However, there was visible joint effusion. On her second visit to OPD, the patient was asked to take a PCR test to detect parvovirus. PCR report came out positive. However, antiviral markers for detection of hepatitis B and hepatitis C, HBsAg, IgM anti-HB core antibody, anti-HBs, and anti-HBs, all were found negative. Parvovirus B19 IgM and parvovirus B19 IgG were also decreased over time ( Table 4).

Diagnosis and management
From the above-given reports, it was clear that the patient was suffering from parvovirus-induced hepatitis as the patient had developed jaundice and there were associated symptoms of abdominal pain, anorexia, and nausea. Similarly, aspartate transaminase (AST) and alanine transaminase (ALT) were highly raised and PCR test came out positive for parvovirus. This verified the ultimate diagnosis as parvovirus-induced seronegative symmetrical polyarthropathy and acute hepatitis. The patient was in close contact with young primary school children, who could have been suffering from parvovirus itself but also were capable of transmitting it.
As a result of this diagnosis, the patient's first-care strategy included a parenteral course of ceftriaxone, paracetamol, and a normal saline infusion. Additionally, the methylprednisolone 1000 mg was given to the patient in pulses for five consecutive days. Antiviral medications were also prescribed to the patient including ribavirin and pegylated interferon. As expected, the outcomes were dramatic and favorable, resulting in a major improvement in the patient's symptoms.