UNCORRECTED PROOF 1 2 Detection of Parvovirus B19 and Chlamydophila 3 pneumoniae in a Patient with Atypical Sarcoidosis 4 5 C. Contini, D. Segala, R. Cultrera, V.M.M. Crapanzano 6 Summary 7 We present an elderly female patient with fever, aplastic 8 anemia, arthralgic symptoms and atypical pneumonia. Sero- 9 logical and clinical findings suggested Parvovirus B19 and 10 Chlamydophila pneumoniae infection. These supposed infec- 11 tions delayed the recognition of underlying sarcoidosis which 12 definitive diagnosis was reached through a lung biopsy and 13 histological demonstration of nonnecrotizing granulomas 14 containing giant cells and noncaseating epithelioid cells. The 15 present case highlights the potential difficulty to diagnose 16 sarcoidosis in the presence of unusual infections which may 17 complicate the course of this disease. 18 19 Infection 2007 20 DOI 10.1007/s15010-007-6313-7 21 22 Introduction 23 Sarcoidosis is a systemic granulomatous and multiorgan 24 disease that has a wide variety of clinical manifestation 25 and can mimic a number of other diseases. 26 The pathogenesis of this disorder is not yet known; 27 moreover, there is no evidence that sarcoidosis is caused 28 or initiated by an infectious agent. 29 The evidence for an infective etiology, particularly 30 mycobacterial, has been postulated even with the advent 31 of molecular tools, but the debate has not been resolved 32 [1]. The search for other infective agents responsible for 33 sarcoidosis has been expanded to other pathogens, but no 34 definitive result was reached so far. 35 The diagnosis of sarcoidosis is based on a combination 36 of clinical, radiographic and histological findings. How- 37 ever, biopsy evidence of a mononuclear cell granuloma- 38 tous inflammatory process is mandatory for a definitive 39 diagnosis. 40 In this report, we describe a patient with supposed 41 mixed Parvovirus B19 and Chlamydophila pneumoniae 42 infections, which delayed the final diagnosis of sarcoidosis. 43 Case Report 44 In December 2004, a 72-year-old female had been hospitalized 45 for 2 weeks in a Regional Medical Hospital (Ferrara, Italy) be- 46 cause she had suffered from fever, transient rash and cough. A 47 chest radiograph had revealed a dishomogeneous infiltrate in the 48 right middle and lower lung fields in the absence of hilar 49 lymphadenopathy (Figure 1). Laboratory findings obtained at 50 that time revealed a peripheral white blood cell (WBC) count of 51 3.6 · 10 9 per liter and a hemoglobin level of 9.7 g/dl, red blood 52 cell (RBC) count of 3.1 · 10 9 per liter and hematocrit 27%. 53 Platelets were 89.6 · 10 9 per liter. The partial thromboplastin 54 time, prothrombin time, serum glucose, liver transaminases, 55 electrolytes and serum creatinine were all normal. Protein elec- 56 trophoresis revealed polyclonal hypergammaglobulinemia and 57 there was cryoglobulinemia. The erythrocyte sedimentation rate 58 was 60 mm/h; the C-reactive protein level was 8.9 UI/ll (refer- 59 ence in our laboratory 05–1.0 UI/ll). Absolute CD4 and CD8 T 60 lymphocyte counts showed no abnormal values. No micro- 61 organisms including acid fast bacilli or foreign bodies were ob- 62 served in either sputum Gram’s stain or culture. Blood and 63 culture of urine were negative. A bone marrow biopsy showed 64 normal cell distribution. Conditions associated with decreased 65 red cell production were not identified. The results of common 66 routine serological tests were all negative. The search of anti-C. 67 pneumoniae antibodies did detect IgG (titre 1:24) with micro- 68 immunofluorescence test (ServiMIF Chlamydia IgG/IgM, Delta 69 biological S.r.L, Pomezia, Italy) in the absence of IgM. Specific 70 IgA antibodies were not investigated at this time. Anti-Parvo- 71 virus B19 IgM without IgG (recomWell Parvovirus B19, Mikr- 72 ogen, Germany) were found in two paired serum samples 73 obtained at entry and after discharge from hospital. 74 The patient received 2 units of packed RBCs and 1 of 75 platelets and was treated with oral steroids for less than 2 weeks 76 which partially relieved her symptoms and restored her hemat- 77 ocrit level to 38% (reference 40–54%). She was discharged from 78 the above hospital in December 2004 with a diagnosis of Par- 79 vovirus B19 infection. 80 On February 2005, the patient was referred to Day Hospital 81 of Infectious Diseases of University of Ferrara because of low- 82 grade fever (37.6 °C), sweats, dry cough and chills, hoarseness 83 and mild dyspnea. The physical examination was unremarkable C. Contini (corresponding author), D. Segala, R. Cultrera, V.M.M. Crapanzano Faculty of Medicine, Section of Infectious Diseases, Dept. of Clinical and Experimental Medicine, University of Ferrara, via Fossato di Mortara 23, 44100 Ferrara, Italy; Phone: (+39/532) 291310, Fax: -291391, e-mail: cnc@dns.unife.it Received: November 4, 2006 Æ Revision accepted: June 11, 2007 Published online: Infection Case Report Infection 2007 Ó URBAN &VOGEL 1