Critical Care: Critical Care |

How Parvovirus and HHV-6 Make Their Way to the ICU FREE TO VIEW

Avery Smith, MD; Adan Mora, MD
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Baylor University Medical Center, Dallas, TX

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;149(4_S):A139. doi:10.1016/j.chest.2016.02.145
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SESSION TITLE: Critical Care

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, April 17, 2016 at 11:45 AM - 12:45 PM

INTRODUCTION: Adult-Onset Still’s disease is a rare inflammatory disease characterized by an evanescent rash, fever and arthritic symptoms. Genetic and infectious etiologies have been proposed as inciting factors. We present a case of confirmed parvovirus and HHV-6 induced systemic inflammation leading to aseptic meningitis and shock requiring intensive care management.

CASE PRESENTATION: A 57 year old Japanese woman with a past medical history of Hashimoto’s thyroiditis presented to the emergency department with 7 days of fever, sore throat, arthralgias, rash, neck stiffness and headache. Physical exam revealed hypotension, erythematous rash and confusion. She was admitted to the Intensive Care Unit (ICU) and started on intravenous fluids, norepinephrine drip and antibiotics. Laboratory testing showed a neutrophilic leukocytosis, slight anemia, azotemia and transaminitis. A lumbar puncture was performed but was negative for any signs of inflammation or infection. Significant laboratory results included a positive parvovirus PCR (IgM/IgG were negative) and a positive PCR elevation of HHV-6. Erythrocyte sedimentation rate was elevated at 91mm/h, C-reactive protein at 33mg/dL and ferritin at 1919ng/mL. She remained in the ICU for 3 days requiring vasopressor support. Her rash began to fade and cultures returned negative but she continued have neck stiffness, fever and headaches. Repeat lumbar puncture was again negative for infection, so non-infectious etiologies were considered. She was treated with high dose prednisone. Overnight, her symptoms improved. The sedimentation rate remained elevated but her azotemia and transaminitis resolved. Ultimately, her condition stabilized and she was discharged with a steroid taper.

DISCUSSION: Adult-Onset Still’s disease is an uncommon rheumatologic syndrome that can mimic infectious meningitis and septic shock. It is a diagnosis of exclusion but certain symptomology and laboratory findings can help support the diagnosis. If made, treatment focuses on immune-suppressive therapy since this is a disorder of systemic inflammation. Acute parvovirus and HHV-6 viral infections appear to have triggered this patient’s immune dysregulation.

CONCLUSIONS: Successful management of shock requires an understanding of inciting factors. Inflammatory causesare a less common, but a real etiology and require a high index of suspicion. Adult-Onset Still’s is one such entity to consider in patient’s with shock who may have fever, arthralgias and a rash.

Reference #1: Bywaters, EG. Still’s disease in the adult. Ann Rheum. 1971;30:121-33.

Reference #2: Kotzias, Apostolos, and Petros Efthimiou. “Adult-Onset Still's Disease: Pathogenesis, Clinical Manifestations and Therapeutic Advances.” Drugs 68 (2008):319-37.

DISCLOSURE: The following authors have nothing to disclose: Avery Smith, Adan Mora

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