By E. Richard Stiehm, M.D.
Several years ago, while reviewing the patients for my immunology clinic, one in particular caught my attention.
Ben, a 10th grader, had been ill for two years, ever since he developed fever, diarrhea and dehydration while on a camping trip. Since then, he had unremitting fatigue, poor sleep, intermittent fevers and rash, weakness and leg pains.
Prior tests had ruled out anemia, infectious mononucleosis and other infections. Ben had antibodies to many viruses and vaccines, indicating a normal immune system. When I examined him, Ben was listless and depressed. He had low-grade fever and flushed cheeks, but there were no other findings. I repeated some tests and added a few
more for rare immune disorders.
My working diagnosis was chronic-fatigue syndrome (CFS) - disabling fatigue, anxiety, depression, non-restorative sleep, aches and pains and short attention span. Ben fit the demographics - upper-middle class, Caucasian and a high achiever with a heavy schedule. But there were three things weighing against CFS: He was a boy; he had a sudden onset of illness; and, most important, he was very interested in why he was ill. He did not exhibit la belle indifference, a lack of concern or interest in his illness.
Most adolescents with CFS don't really seem to mind their illness. Consciously or unconsciously, it gives them time out from their busy schedule. But Ben was keenly interested, interrupting his mother to supply additional details for her narrative.
When the tests came back, one result stood out. A previous test had shown that Ben had antibodies to parvovirus, which causes slapped-cheek syndrome, a common febrile illness of childhood. These children develop long-lasting IgG antibodies that prevent a second attack. But the UCLA lab found both IgG antibodies and short-acting IgM antibodies,
indicating recent or persistent infection.
|Dr. E. Richard Stiehm is a professor of pediatrics and allergy and immunology in the David Geffen School of Medicine at UCLA.|
Could Ben have chronic parvovirus? A molecular PCR (polymerase chain reaction) test to measure parvovirus in the blood came back strongly positive. We had a diagnosis!
The only treatment for chronic parvovirus is human immunoglobulin (gamma globulin) made from normal plasma containing antibodies to most infectious agents, including parvovirus. Ben returned to the clinic for his first large dose of intravenous immunoglobulin (IVIG). That night, he awoke with nausea, headache and a stiff neck. He had a rare severe side effect of IVIG called aseptic meningitis. It resolved after 24 hours, but it was a very scary and unpleasant experience.
The next week I reduced the IVIG dose and gave Ben acetaminophen and diphenhydramine, and later I gave him IVIG subcutaneously at a still lower dose. The injections were tolerated, but his symptoms persisted and the PCR test remained positive.
My only alternative was to go back to high-dose IVIG preceded by a hefty infusion of hydrocortisone. Fortunately, Ben now tolerated the infusions. After four infusions, Ben began to feel better, and after four more months, the parvovirus in his blood was absent. I stopped the infusions and the blood test remained negative. I pronounced him cured.
The physician who treated Ben earlier, Dr. Myron Liebhaber, happened to be in my clinic the day we saw Ben for the last time. "Myron," I said, "this is such an interesting case, we should definitely write a case report." Ben perked up his ears: "Write a medical article about me? How about if I write the article?" Myron and I looked at each other. Why not?
I showed Ben how to access the National Library of Medicine, gave him my reprints and sent him home. A few weeks later, he sent me his report for his science class, including electron-microscopic pictures and articles on three adults with CFS due to parvovirus.
We polished his report, and it was promptly accepted by the Pediatric Infectious Disease Journal. You can bet that a high school student who has co-authored a peer-reviewed paper about his own illness will catch the eye of most college admission officers. Indeed, Ben completed UC Irvine, and in May he graduated from the physicians-assistant
program at USC.
Photos: Courtesy of Benjamin Kaska
Dr. E. Richard Stiehm is a professor of pediatrics and allergy and immunology in the David Geffen School of Medicine at UCLA.
Photo: Courtesy of Dr. E. Richard Stiehm