279 BRIEF REPORT HUMAN PARVOVIRUS B19 DNA IN SYNOVIAL FLUID B. A. C. DIJKMANS, A. M. W. VAN ELSACKER-NIELE, M. M. M. SALIMANS, G. A. E. DE VRIES, and H. T. WEILAND We describe a 33-year-old woman with a serologically proven human parvovirus B19 infection, who developed synovitis. Using a dot-blot hybridization technique, we detected B19 DNA in her synovial fluid. To our knowledge, this is the first report of the isolation of B19 from synovial fluid. The association of acute viral diseases, such as hepatitis B, mumps, and rubella, with transient arthritis has for many years been considered as support of the hypothesis that viruses can be etiologic agents in chronic arthritides in humans. In particular, infection with the rubella virus is known to produce an acute synovitis, which although normally self-limited, has been reported to recur months or years after the acute stage in some cases (1,2). During recent years, attention has been focused on the human parvovirus B19; infection with this virus, too, can lead to arthralgia or frank arthritis, especially in adult women (3,4). However, there is only l previously published report of an attempt to isolate B19 from synovial fluid; in that study, B19 DNA was sought in the synovial fluid of 1 patient, but was not found (5). We report here our From the Departments of Rheumatology and Virology, University Hospital, Leiden, The Netherlands. B. A. C. Dijkmans, MD: Department of Rheumatology; A. M. W. van Elsacker-Niele, MD: Department of Virology; M. M. M. Salimans, PhD: Department of Virology; G. A. van Albada-Kuipers, MD: Department of Rheumatology ; E. de Vries, PhD: Department of Rheumatology; H. T. Weiland, MD: Department of Virology. Address reprint requests to B. A. C. Dijkmans, MD, S t d Centre Rheumatology, Building 1, C2-Q, Leiden University Hospital, PO Box 9600, 2300 RC Leiden, The Netherlands. Submitted for publication April 10, 1987; accepted in revised form July 9, 1987. Arthritis and Rheumatism, Vol. 31, No. 2 (February 1988) VAN ALBADA-KUIPERS, findings of B19 DNA in the synovial fluid of a patient with a serologically proven B19 infection. Case report. The patient, a previously healthy 33-year-old woman, was referred to the outpatient clinic of the Department of Rheumatology, Leiden University Hospital, because of pain in her right shoulder, wrist, knee, ankle, and the proximal interphalangeal (PIP)joints of both hands. These arthralgias had developed within 24 hours after the onset of an acute febrile illness with a transient rash. On examination, no abnormalities were found, except for swelling of both knees and of the PIP joints of both hands. The findings of radiographs of the hands and feet were normal. The patient’s erythrocyte sedimentation rate was 23 mm/hour (Westergren), the hemoglobin level was 8.3 mmolesfliter, and the white blood cell count was 5.0 x 109/liter with a normal differential cell count. The results of Rose-Waaler and latex fixation tests were negative; antinuclear antibody was borderline positive. HLA-DR4 was absent. Serologic studies ruled out recent infection with the rubella virus. However, a serum sample obtained when the patient was first seen contained B 19-specific IgM antibodies, as detected by radioimmunoassay (18 arbitrary units; normal 5 5 ; determined by Dr. M. J. Anderson, London, UK) indicating recent B 19 infection. Analysis of synovial fluid from the right knee showed a white blood cell count of 6.5 x 103/mm3,with 66% mononuclear cells; crystals were not seen, and no microorganisms could be cultured. A dot-blot hybridization technique was used to examine the synovial fluid for B19 DNA, after reduction of viscosity by hyaluronidase treatment (7). This technique uses single-stranded, labeled DNA as a probe to detect complementary DNA. DNA was ex- BRIEF REPORTS 280 tracted from the synovial fluid, and B19 DNA was found with a 32P-labeled B19 probe (8) (Figure 1) which was kindly provided by Dr. M. J. Anderson. Synovial fluid from a control patient whose serum contained no B19 IgM was treated in the same manner, and gave negative results (Figure 1). Our patient’s arthralgias and general malaise persisted for 3 months, but she recovered completely. Discussion. To the best of our knowledge, this is the first description of the presence of B19 DNA in the synovial fluid of a patient with a serologically proven B19 infection. It must be kept in mind that arthritis seen in natural and experimental B19 infections in humans develops after the virus has disappeared from the circulation (9). The presence of B19 DNA in synovial fluid in the present case suggests joint invasion by the virus. The technique we used does not show whether the arthritis was due to direct infiltration by the virus or to an immunologically mediated phenomenon. During recent years, parvoviruses have received attention in connection with the etiology of rheumatoid arthritis (RA). One of these viruses, designated RA-1, was isolated from synovial tissue of a patient with RA and proved to be pathogenic in mice (10). However, the RA-1 virus is antigenically different from the B19 virus, and no similarities have been found in restriction enzyme analysis of the RA-1 virus and several known parvoviruses (10). Attempts to establish a link between persistent arthritis after B19 infection and RA have been based on the presence of HLA-DR4, which occurs more frequently in RA patients than in the general population (11). Reports on the frequency of DR4 in patients with persistent arthritis after B 19 infection are conflicting: Klouda et al (12) found an increased frequency, but in a previous study, we did not (13). The DR4 antigen was absent in our patient. Our finding of B 19 DNA in the synovial fluid of a patient with a serologically proven B19 infection lends support to the possibility that parvovirus infection can play an etiologic role in RA. REFERENCES I . Chandler JK, Ford DK, Tingle AJ: Persistent rubella infection and rubella-associated arthritis. Lancet I: 13341335, 1982 Figure 1. Autoradiograph of a nitrocellulose filter, showing DNA isolated from 4 samples. A l , DNA from the synovial fluid of a patient who was seronegative for B19 IgM. B1, DNA from the synovial fluid of the patient described in the present report, who was seropositive for B19 IgM. A2, DNA from the serum of another BIPinfected patient (positive control). B2, DNA from the serum of a patient who was seronegative for B19 IgM (negative control). 2. Grahame R, Armstrong R, Simmons N, Wilton JMA, Dyson M, Laurent R, Millis R, Mims CA: Chronic arthritis associated with the presence of intrasynovial rubella virus. Ann Rheum Dis 42:2-13, 1983 3. Reid DM, Reid TMS, Brown T, Rennie JAN, Eastmond CJ: Human parvovirus-associated arthritis: a clinical and laboratory description. Lancet I: 422-425, 1985 4. White DG, Woolf AD, Mortimer PP, Cohen BJ, Blake DR, Bacon PA: Human parvovirus arthropathy. Lancet I: 419-421, 1985 5 . Rowe IF, Deans AC, Midgley J, Anderson MJ, Keat AC: Parvovirus infection in hospital practice. Br J Rheumatol 26: 13-16, 1987 6. Cohen BJ, Mortimer PP, Pereira MS: Diagnostic assays with monoclonal antibodies for the human parvoviruslike virus (SPLI’). J Hyg (Lond) 91:113-130, 1983 7. Clewley JP: Detection of hum,n parvovirus using a molecularly cloned probe. J Med Virol 15:173-181. 1985 8. Anderson MJ, Jones SE, Minson AC: Diagnosis of human parvovirus infection by dot-blot hybridization using cloned viral DNA. J Med Virol 15:163-172, 1985 9. Anderson MJ, Higgins PG, Davis LR, Willman JS, Jones SE, Kidd IM, Pattison JR, Tyrrell DAJ: Experimental parvoviral infection in humans. J Infect Dis 152:257-265, 1985 BRIEF REPORTS 28 1 10. Simpson RW, McGinty L, Simon L, Smith CA, Godzeski CW, Boyd R: Association of parvoviruses with rheumatoid arthritis of humans. Science 223:1425-1428, 1984 1 1 . Stastny P: Association of the B cell alloantigen DRw4 with rheumatoid arthritis. N Engl J Med 298:869-871, 1978 12. Klouda FT, Corbin SA, Bradley BA, Cohen BJ, Woolf AD: HLA and acute arthritis following human parvovirus infection. Tissue Antigens 28:318-319, 1986 13. Dijkmans BAC, Breedveld FC, de Vries RRP: HLA antigens in human parvovirus arthropathy. 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