Periferal neuropathy has been associated with Parvovirus B19. Brachial plexus involvement has been previously described, but diaphragmatic paralysis and gastroparesis as a consequence of this infection has not been reported yet.
We present the case of a 60 year old female with new onset of unilateral diaphragmatic paralysis following a confirmed Parvovirus B19 infection. Her past medical history includes controlled hypothyroidism, GERD and asthma. She developed a 9 to 10 day illness consisting of flu-like symptoms, a maculo-papular erythematous rash that started in her lower extremities and then ascended to her neck, and persistent pain in her anterior neck and shoulders bilaterally. Laboratory work revealed an elevated erythrocyte sedimentation rate (ESR) and positive IgG and IgM Parvovirus B19 antibodies one week after the onset of symptoms. There was a known exposure to a child with confirmed Parvovirus B19 infection prior to the onset of her symptoms. Workup for other infectious or rheumatologic conditions was negative. An initial CXR obtained prior to the onset of symptoms was normal and one taken 2 weeks later for evaluation of shortness of breath revealed elevation of the left hemidiaphragm. Diaphragmatic paralysis was confirmed by fluoroscopic imaging. She also developed bloating and early satiety consistent with gastroparesis.
We believe our patient suffered from a Parovirus B19 infection that resulted in a left phrenic nerve injury and hemidiaphragm elevation. This virus has previously been associated with peripheral nerve damage. Two reports describe involvement of the brachial plexus with resulting pain and weakness in the shoulder girdle, as well as sensory deficits in the upper extremities (1, 2). The relation between viral infections and nerve demyelination has also been demonstrated.Our patient had a normal chest X-ray at the onset of her viral illness and one that showed a new left-sided diaphragmatic elevation 2 months after developing an immunologic response to Parvovirus B19. Her persistent shoulder pain could be an indicator of brachial plexus involvement as well. Drug related nerve damage is unlikely since she only received ketorolac, oxycodone, levothyroxine and bronchodilators during this period. She does not drink alcohol or use intravenous drugs, her thyroid function was controlled during this episode and she is not diabetic, which makes metabolic causes unlikely.
Given the timeframe and absence of more common causes of peripheral neuropathy, our patient’s new onset of left sided diaphragmatic paralysis and gastroparesis seems to be a consequence of a Parvovirus B19 infection.
Martin Karlicek, No Financial Disclosure Information; No Product/Research Disclosure Information