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Clinical and Molecular Evidence for Association of SLE with parvovirus B19
M. Pavlovic, A. Kats, M. Cavallo and Y. Shoenfeld
Lupus 2010 19: 783
DOI: 10.1177/0961203310365715
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Lupus (2010) 19, 783792

http://lup.sagepub.com

REVIEW

Clinical and Molecular Evidence for Association

of SLE with parvovirus B19
M Pavlovic1, A Kats2, M Cavallo2 and Y Shoenfeld3
1

Department of Computer and Electrical Engineering and Computer Science, Florida Atlantic University, FL, USA;
2
Department of Biological Sciences, Florida Atlantic University, FL, USA; and 3Department of Medicine B and
Center for Autoimmune Diseases, Sheba MedicalCenter (Affiliated to Tel-Aviv University), Tel-Hashomer 52621, Israel

In addition to genetic and environmental factors, viruses have been suspected as causes and/or
contributors to human autoimmune diseases, although direct evidence for the association is
generally lacking. Parvovirus B19, the cause of Fifth disease in childhood, and possible trigger
in the spectrum of autoimmune diseases in adults, has emerged as one of the central viral
candidates within the last few years. In this article we propose a possible model for parvovirus
B19 association with systemic lupus erythematosus (SLE). The basis for our model is the
secretion of hydrolyzing anti-ssDNA autoantibodies in 3070% of cases with SLE, which
in turn can either hydrolyze viral B19 ssDNA in blood and other fluids, or intranuclear,
replicated viral ssDNA after re-activation and translocation of the virus into the nucleus
of the host permissive cells. Both mechanisms contribute to perpetuation and maintenance
of a vicious cycle with concomitant flares in SLE, and involve inevitable TLR9 sensitization
and genetic switch for anti-ssDNA autoantibody production from activated B cells in individuals prone to triggering. This model strongly suggests a major potential impact upon early
prevention (vaccination) and targeted therapy of this subclass within the SLE spectrum of
diseases. Incorporated in this new concept is an innovative idea for developing the tool for
more precise (individualized) diagnosis, prevention, and therapy. Lupus (2010) 19, 783792.
Key words: autoimmune diseases; cytokine microarray profiling; hydrolytic anti-DNA
autoantibodies; parvovirus B19; systemic lupus erythematosus (SLE)

Introduction
Background
The cause of lupus is unknown but a number of
disease agents have been implicated.1,2 Epstein
Barr virus, parvovirus B19, bacterial species and
drugs have been connected to the disease.38 The
presence of viruses was sought in a colony of
dogs bred from parents with systemic lupus erythematosus (SLE).4 Cell-free ltrates prepared from
the spleens of these animals were injected into newborn dogs, mice, and rats. The canine recipients
developed antinuclear antibody (ANA) and positive lupus erythematosus (LE) cell tests, proving
Correspondence to: Dr Mirjana Pavlovic MD, PhD, Research
Professor, Department of Computer and Electrical Engineering and
Computer Science, Florida Atlantic University, 777 Glades Rd,
Boca Raton, FL, 33431, USA
Email: mpavlovi@fau.edu or pmirjana@aol.com
Received 27 October 2009; accepted 15 February 2010

that the illness is transmissible4 and, with respect

to injection with cell-free ltrate, probably of viral
origin. Lupus patients exhibit an interferon alpha
(IFN-a) signature, suggesting an underlying infection of yet unknown origin.9,10 Therefore, the key
question is what agent or agents drive the inammation and elicit the inammatory cascade in SLE?
The parvovirus is at the focus of many dermatologic and rheumatologic disease-related studies
previously attributed to unknown factors.1121
Initially, B19 was identied as the causative agent
of erythema infectiosum (erythrovirus), a common
childhood rash found in outbreaks among schoolchildren during the winter and spring months, later
called Fifth disease or slapped cheek disease.2225
Since then, B19 has been shown to be the causative
agent of many diseases, some of them classied as
autoimmune in origin, including arthropathy, transient aplastic crisis, persistent anemia, and hydrops
fetalis (Table 1). Yet, its best known infection
remains erythema infectiosum or Fifth disease,22

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10.1177/0961203310365715

Clinical and Molecular Evidence for Association of SLE with parvovirus B19
M Pavlovic et al.

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Table 1

Major diseases caused by parvovirus B19

Disease

Actue or Chronic

Host

Fifth Disease
Arthopathy

Normal children
Normal adults

Transient aplastic crisis

Acute
Acute or
chronic
Acute

Persistent anemia

Chronic

Hydrops fetalis and

congenital anemia

Acute or
chronic

Patients with increased

erythropoiesis
Immunodeficient and
immunocompromised
patients
Fetus

With courtesy and permission of http://www.aafp.org/afp/20041115/

tips/5.html website.26

attacking mostly children of both sexes. The growing evidence of data based on in situ polymerase
chain reaction (PCR) demonstrated B19 DNA
and tumor necrosis factor alpha (TNF-a) messenger ribonucleic acid (mRNA) in endothelia,5 broblasts,5 mast cells,27 lymphocytes,7 synovial
tissues,27 and perivascular inammatory cells in a
spectrum of autoimmune diseases, ranging from
SLE and scleroderma, to mixed connective tissue
disease (MCTD).58,27
Presently, there is no ecient vaccine for human
parvovirus B19, despite several trials using viral
capsid proteins.23 The reasons for this failure are
not quite clear. However, a new cell line has been
developed recently that can produce inactivated
B19 viral capsid protein, specically VP1, as it is
the primary antigen during native viral infections.28
Based on sequence homology data, a phospholipase
A2 motif has been identied in the VP1 unique
region
of
parvovirus
B19,
similar
to
Adeno-Associated Virus-2 (AAV-2).29 It seems to
be a common idea that a successful vaccine based
on an inactivated viral capsid protein would help to
prevent outbreaks of Fifth disease in schools, as
well as eliminate any risk associated with infection
of B19 during pregnancy (hydrops fetalis). If parvovirus B19 is involved in triggering lupus disease,
at least in one portion of the lupus spectrum of
diseases, such a vaccine would be of preventive
importance for the development of SLE.
Statistics and significance
Infection by parvovirus B19 is most common
between 6 and 15 years of age. Some 2554% of
adults have already had parvovirus B19 infection.30
Estimated incidence of infection shows that 85%
people over 70 years are infected, rising to 90%
when closer to the end of life.30 Women show
higher prevalence then men. On the other hand, a

small part of the population is naturally immune,

since they do not have the receptor for the virus
(globoside P), which enables the virus to penetrate
into the cell. This also holds true for p phenotypes
of the Amish population.25

Hypothesis
Our hypothesis is that a diverse array of infectious
agents may be involved in eliciting the inammatory symptoms of lupus.31,32 The cause of the disease is specic to an individual and the immune
response of the individual. No single agent causes
all cases of lupus any more than any single carcinogen causes all cases of cancer. Therefore, SLE is a
spectrum of diseases (i.e. a syndrome), rather than
a single disease. For the reasons explained above,
we hypothesize that one of the infectious triggers of
lupus could be parvovirus B19, contributing to a
certain percentage within the spectrum of SLE
syndrome.3134

Important viral Features

Parvovirus: details of structure and its use in
clinical practice
Human parvovirus B19 can be found in blood, bone
marrow (BM), liver, leukocytes, and synovial
uid.27,35,36 Respiratory droplets and blood products are important from an epidemiological
point of view. The virus has an icosahedral shape,
forming 1826 mm diameter particles (50% protein
and 50% DNA, each). Without envelope, B19
alludes to the sample from which the parvovirus
was rst discovered (5.5 kb ss-DNA). Its DNA has
palindromic sequences with Inverted Terminal
Repeats (ITRs) of about 383 nt in length, which
forms hairpins, and therefore the entire structure
tends to self-fold (Figure 1). Viral DNA disappears
from blood very quickly, but can be found for years
in BM, synovial tissues and liver, suggesting the persistence of the virus in the body and possible
re-activation. Detection of parvovirus B19 DNA
in blood is performed by nested PCR with 322 bp
nested PCR product. Comparing dierent autoimmune diseases (rheumatoid arthritis (RA), Sjogrens
syndrome (SS), SLE, rheumatoid purpura (RP), primary billiary cirrhosis (PBC), autoimmune inner ear
disease (AIE)), only sera of patients with SLE and
AIE were found to have B19 DNA.6
The viral capsid is simple and has three coat
proteins: VP1 and VP2 (capsid proteins, structural

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Clinical and Molecular Evidence for Association of SLE with parvovirus B19
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785

Generic Parvovirus genome

Terminal
palindrome

P
Promoter

REP

CAP

Non structural
(NS) proteins

Structural (virion)
proteins (VP)

PolyA

Figure 1 Schematic presentation of Parvovirus B19 genome. http://www.medynet.com/usuarios/nnuneza/virologia/parvoviruses.htm.

Thanks to kindness of the author, Dr Joey Oakley from his unpublished notes.37

with no enzymatic activity, but antigenic in nature

causing IgM and IgG formation), and NS1, a
non-structural protein produced during virus infection.38 Parvovirus IgM and IgG specic antibodies
can be detected from blood samples by using a variety of methods.3840
The laboratory diagnosis (Table 2) of parvovirus
B19 is problematic due to the false positive IgM
and presence of detectable B19 DNA in healthy
persons. While IgM response persists 1012 days
after exposure, IgG response probably persists for
life.41 Transfection seems to be most directed to
erythroid progenitor cells. There is a remarkable
viral tropism for erythroid early progenitors, the
basis of which is the globoside, blood group antigen
P, tetrahexosoceramide (a glycolipid of erythrocyte
P antigen). Some studies suggest tissue tropism of
B19 beyond the erythroid progenitor cells, such as
leukocytes.7 Indeed, although in illness they are
present in giant pronormoblasts, they can also be
found in fetal liver, normal leukocytes, synovial,
myocardial, and endothelial cells (a cause for
urgency) and a few leukemic cell lines. Therefore,
dierent receptors for entry into the cells are suggested.29 Yet, it is considered that natural resistance
to the virus occurs in people without blood group P
antigen (natural receptor), even though those individuals are very rare.42 A signicant characteristic
of parvovirus B19 is to replicate selectively in dividing cells of BM, gastrointestinal tract (GIT), and
embryonic cells. The virus is sensitive to heat, acid,
and alkali denaturation. DNAse 1 degrades B19
DNA at 60 C within 10 min (pasteurization).43
Viral capsid is also destroyed by pasteurization.
Culture
There is no animal model for B19, and the virus can
only be grown in culture with diculty. In vitro studies of B19 in explanted human BM cultures have
conrmed the erythroid specicity of this virus.44
B19 can be cultured in erythroid progenitor cells
from a variety of sources, including human BM,44
fetal liver,45 umbilical blood, and peripheral

Table 2 Laboratory diagnosis for parvovirus infection

Unexposed
Acute Infection(37days)
Acute Infection(714days)
Previous Infection
Immuno compromised patient

IgM

IgG

PCR for
DNA

1
2

Increased IgM may be detectable for up to 9 months post infection;positive PCR results have been observe up to 9 months
post-infection as well.
2
Recent versus reactived versus previous infection with parvovinus in
an humorally compromised patient will rely greatly on the clinical
history for proper interpretation of nucleic acid testing for parvovinus.
With kind permission of author,Dr Stephen Dewhurst from Rochester
University,at:http:/path.upmc.edu/cases/case522/images/Table-1.gif46

blood.41,47 In all culture systems, erythropoietin is

required to maintain viral replication, probably by
supporting the rapid division of erythroid progenitors. However, B19 can also be propagated in a few
specialized cell lines: two megakaryoblastoid cell
lines, MB-0248 and UT-7/Epo,49 and two human erythroid leukemia cell lines, JK-150 and KU812Ep6.51
These lines have been used to study mechanisms of
replication and to develop neutralization52 and
infectivity assays.51 However, the yield of virus
from all of these cultures is poor, and they cannot
be used as a source of antigen for diagnostic tests.
Viral anti-ssDNA and viral cycle (replication)
General features

The replication of the parvovirus is closely linked to

host cellular replication. The virus replicates in the
nucleus of erythroblasts or other permissive cells,
but initiates replication only after the host cell has
completed the S phase of the cell cycle, and uses
cellular DNA polymerases. Studies have shown
that either the a or b polymerases are utilized by
bidirectional nucleotide incorporation forming a
nucleotide single-stranded (ss) sequence, which
forms double strands but not of helicodal conformation, as shown in Figures 2 and 3. The existence of a
hitherto unknown cell-specic transcription factor
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Clinical and Molecular Evidence for Association of SLE with parvovirus B19
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utilized by parvovirus B19 is suggested.53 Hairpin

structures are critical for virus replication, although
the subtle details of replication are still unknown.
Two models are proposed for viral replication, and
both of them use palindromic sequences on terminal
hairpin structures as a primer for that purpose.
Specific steps of replication

1. Parvovirus DNA replication is accounted for by

a single-strand displacement model, similar to
that used to describe adenovirus DNA replication.54 There are two stages of replication, both
using terminal DNA sequences as primers. Thus,
RNA or protein primers or primases are not
involved. This model predicts site-specic cleavage of intermediates during the replication.
2. The DNA replication of the parvovirus can also
be thought of as a modied rolling hairpin. The
ends of the viral genome are palindromic.
In order to initiate DNA synthesis, the 30 end
of the viral genome folds back on itself to
become a primer.55 After some DNA synthesis
along the complementary strand,5659 the 30 terminus of the complementary strand folds into a
hairpin structure to serve as a primer for further
DNA replication.60 Replication continues along
the complementary strand. As a next step, an
obligatory dimer duplex replicative intermediate
structure is formed. Within the palindrome
regions lie small, unpaired sequences which
serve as the cleavage sites for the NS1 nuclease.
The nuclease subsequently becomes covalently
attached to the 50 side of the nick.61 DNA replication continues along the viral progeny
strand.62 In the nal steps,6365 capsid protein
recognizes the 30 hairpin structure and packages
of the single strands. About 1826 DNA nucleotides at the 50 end, along with NS1, are found
outside the capsid. These extra sequences will be
cleaved o in the extracellular environment or
upon entry into the host cell.
Sequence variability
The nucleotide sequence of B19 was originally established by sequencing a viral isolate designated
pvbaua obtained from the serum of a child with
homozygous sickle cell disease.64 Since then, a
large number of isolates have been sequenced
entirely or in part. Sequence dierences can be detected by restriction enzyme analysis, single-stranded
conformational polymorphism analysis of PCR products, and sequencing, by multiple alignments. The
reported B19 isolates are all intimately clustered and

show only 6% divergence among themselves. Not

unexpectedly, the NS1 gene is well conserved
among most eld isolates, consistent with a required
role in virus propagation, while the VP1 and VP2
regions may occasionally show a greater variability
of 23%.61,62 No correlation between specic disease
symptoms and B19 sequence has been observed,63
and the conservation of sequence is such that
sequencing is generally unhelpful in investigating
single-source outbreaks. Recently, a B19 isolate,
tentatively termed V9, was identied in a French
child with transient aplastic anemia, and on
sequence analysis this isolate was seen to be markedly (>11%) dierent from other B19 sequences.64
Standard B19 serological tests failed to demonstrate
an acute B19 infection, and therefore it was suggested that the observed aplastic crisis was due to
infection by V9, a putative emerging virus, which did
not show cross-reactivity with B19-specic tests.

Infection: clinical signs and viral re-activation

Parvovirus B19 can be spread by respiratory and
blood route. All parvoviruses require receptor-mediated endocytosis for cell infection. The human parvovirus B19 virus replicates only in human elytroid
progenitor cells, and cells that are already known
to be permissive due to the existence of receptorgloboside/antigen P.60,6668 However, a number of
cells which express globoside on their surfaces are
not susceptible to infection, which may be due partly
to an intracellular blocking of the transcription of
viral messages in non-erythroid cells.60,68 It was also
likely that there is another protein-based receptor
for the parvovirus B19 virus, since Weigel-Kelley
et al. have indicated that P antigen is necessary for
parvovirus B19 binding, but not sucient for virus
entry into the cells.66 Indeed, very soon the same
group of authors has identied a5b1 integrin as a
cellular coreceptor for human parvovirus B19
entry into the cell, using as a model human erythroleukemia cells (K562) which allow parvovirus B19
binding, but not entry.69 They reported that upon
treatment with phorbol esters, those cells became
adherent and permissive for parvovirus B19 entry,
mediated by a5b1 integrins, only in their
high-anity conformation. Thus, in contrast to
mature human red blood cells expressing high
levels of P antigen, but not a5b1 integrins, primary
human erythroid progenitor cells express high levels
of both P antigen and a5b1 integrins, and therefore
allow for b1 integrin-mediated entry of parvovirus
B19.69 The process of cell infection by parvoviruses

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Clinical and Molecular Evidence for Association of SLE with parvovirus B19
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shows many of the features seen for other viruses

which replicate in the nucleus, but the small and
stable parvovirus particles must undergo more
subtle changes during the various steps involved.70
Incubation time is 710 days (range, 421 days).
Transport of the capsid and/or viral DNA into
the nucleus is an important step in infection of
cells with an intact nucleus and occurs principally
through the nuclear pore complex (NPC). Although
small macromolecules can diuse freely through the
pore, transport of larger molecules is specic, requiring ATP and soluble cytosolic factors, and is
mediated by nuclear localization sequences
(NLSs).70 Parvovirus capsids appear to be able to
pass through the NPC intact, and over a period of 2
or more hours, microinjected capsids enter the
nucleus, where they are recognized by antibodies
that bind only intact capsids.70 Modication of
viral capsids may allow exposure of NLSs needed
for nuclear targeting and transport of viral particles.
Clinical studies data indicating the reasons for
association with SLE
State of the art of SLE and parvovirus B19 infection:
pros and cons

Microarray studies have been conducted on lupus

patients.7173 However, these investigations were

limited to expression of human genes. A key molecular signature has been identied through these
eorts, the up-regulation of IFN-a.9,10 The likely
candidate source for this molecule is the plasmocytoid dendritic cell (pDC). However, the agent or
agents expected to induce the IFN-a within a
patient have remained elusive. No studies have
been conducted in an eort to develop a gene
chip or proteonomic display that contains an
array of possible agents, as well as the molecular
signatures of cytokines and antibodies. A more
complex approach is evidently necessary, to explain
the causative factors of lupus disease.
Our hypothesis is that a diverse array of infectious agents may be involved in eliciting the inammatory symptoms of lupus and that one of these
scenarios involves parvovirus B19. There are some
clinical data which are in agreement with parvovirus involvement, although the exact mechanisms
are not elucidated. For example, the episodes of
fever, anemia, and arthralgia are found in patients
diagnosed with SLE, red cell aplasia, and giant erythroblasts, with positive IgM antibodies in serum.74
In parvovirus infection, on the other hand, symptoms and signs are similar, as presented in Figure 2.
Reactivation of the disease by virus74 was found in
42 old women. A 46-year-old woman had B19

B19 Viremia and antibody response

Fever, chills,
headache,
myalgia

Clinical
features

Rash &
arthralgia

Normal values
Hematological
changes

Hemoglobin
Reticulocytes

Dot blot
B19 DNA
PCR

IgG

Viremia
IgM

B19 Viremia and

antibody responses

14

IgG

21

IgM

28

Days

Months

Figure 2 B19 viremia and antibodies response within the time-course of the disease. Erik D. Heegaard and Kevin E. Brown.
Human Parvovirus B19. Clin Microbiol Rev. 2002 July, 15(3): 485505. doi: 10.1128/CMR.15.3.485-505.2002. With authors
and Publishers kind permission.24
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Clinical and Molecular Evidence for Association of SLE with parvovirus B19
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infection followed by serious are of SLE.75 This

also raises the question: is there a parvoviral enhancer of SLE? In another study, a 68-year-old female
with SLE and pure red cell aplasia, antiphospholipid syndrome, IgG HPV, was B19 viral DNA positive at the time of admission.21 Was it a
coincidence or causality? A 26-year-old woman,
three years after being diagnosed with SLE, presented with fever, arthralgia, nausea, vomiting, and
was IgG positive to viral DNA.76 The clinical
examples of the association of SLE and other autoimmune diseases are described by many
authors.7477 There are also quite contrasting data
stating that there is no correlation between parvovirus B19 and SLE, as described by Bengtsson
et al.s study in 2000, of a group of 99 SLE
patients.78 The reason for such results (no IgG
prevalence in comparison to control) could be in
the dierence in sensitivity used in the two assays
applied,78 immunosupression due to drug (steroid)
treatment, or immunosupression due to disease.
However, for similar reasons these data are equally
as convincing as those described by Hsu and Tsau
in 2001, who have found parvoviral B19 DNA only
in patients with SLE and AIE between the spectrum of autoimmune diseases.6 Some of the authors
state that parvovirus B19 causes symptoms that
only mimic lupus disease, such as vasculitis,
arthralgia, and fever episodes.79,80 Taken together,
the clinical data suggest the critical role of uniform,
longitudinal studies, with a strong emphasis on a
uniquely designed approach and evaluation of laboratory and clinical signs in order to conrm association between parvovirus B19 infection and SLE,
beyond reasonable doubt.
Detection of the parvoviral infection is also indicated by typical hallmarks:
. recent infection (IgM antibody assay the third
day after symptoms);
. presence of viral DNA (nucleic acid hybridization, the most sensitive test);
. B19 in leukocytes.81

Indirect experimental proof of possible molecular association of parvovirus B19 and SLE
Anti-DNA hydrolyzing antibodies and SLE
(Abzymes)
The hallmark of SLE is the production of an array
of IgG and IgM autoantibodies directed against

one or more nuclear components, the most frequent of which are double-stranded (ds)
DNA and/or ss DNA. Both anti-ssDNA
and anti-dsDNA are involved in disease development and have been eluted from the kidney biopsies
of experimental murine models and SLE
patients.82,83 Rodkey et al.84 showed that mouse
anti-ssDNA monoclonal antibody BV04-01 has
binding specicities for a hairpin-like structure,
similar to that which ssDNA human parvovirus
B19 DNA has. Furthermore, its DNA sequence
has a number of 5, 6, and 7 thymidine motifs.
Knowing that at least 5 T motifs85 of viral DNA
are necessary to be recognized by the arginine of
the anti-ssDNA antibody in order to bind to three
of them, one can visualize the conditions for
anti-ssDNA hydrolytic antibody action in
this system.
Real-time fluorescent detection of hydrolysis of
the synthetic parvovirus ssDNA sequence by
purified anti-ssDNA antibodies
Quite recently, Cavallo et al.86 have designed
the new uorescence-based real-time method for
monitoring anti-DNA antibody hydrolytic activity.
By using an oligo-probe mimicking the part of parvovirus B19 sequence with thymidine pentamer
for recognition (a prerequisite for antibody binding
to the substrate),85 and isolated and puried
lupus anti-ssDNA antibody using a novel two-step
magnetic bead method30,87 in appropriate proportion and mixture, it was found that hydrolysis
of synthetic sequence occurs in dierent kinetics
compared with commercial DNase1. This strongly
suggests that the DNase activity of the antibody
is its intrinsic property and that due to that property, the antibody can cleave viral DNA. This is
also, to the best of the authors knowledge, the
rst indication of a possible association
between parvovirus B19 and SLE at the molecular
level. The hydrolysis of synthetic parvovirus
B19 ssDNA sequence by lupus anti-ssDNA
antibody could be the molecular manifestation
of an acquired antimicrobial attack of the host
system, part of the anti-DNA antibody clearance strategy from the body, or the direct antinuclear DNA cleavage during ssDNA replication
within permissive host cells with consecutive
cell death and exposure to the immune system
of the new array of antibodies, thereby perpetuating and maintaining the vicious cycle in lupus
disease.

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Proposed model of possible parvoviral B19 and

anti-DNA antibody involvement in SLE and
other autoimmune diseases
This work is intended to summarize clinical and
experimental data which would contribute to the
model of possible parvovirus involvement in SLE.
Our model is given in Figures 3 and 4, and shows
two possible mechanisms of action of lupus
anti-ssDNA hydrolyzing antibodies in serum and
synovial liquid, and at nuclear (cellular) level. In
the rst case anti-ssDNA binding antibody,
secreted from activated B cells, attacks free microbial (parvoviral) DNA and hydrolyzes it, contributing to the clearance of DNA from plasma through
glomeruli, where they can underline basal membrane, alone, or in complex with small pieces of
viral DNA. In the second case, anti-ssDNA hydrolyzing antibodies, after crossing the cell membrane
via cell structural proteins88 and their translocation
into the nucleus, directly bind to, and hydrolyze,
replicating viral ssDNA in dividing cells. This
newly formed viral DNA, built up by utilizing cell
A. In sera: Antimicrobial
strategy and clearance of

B. In cell nucleus: Nuclear DNA hydrolysis by

antiss-DNA nuclear autoantibodies with
perpetuation and maintenance of Vicious cycle

Anti-DNA
antibody
B19
DNA

Figure 3 Model of Parvovirus B19 Association with

Autoimmunity. Pavlovic, M., Kats, A., Shoenfeld, Y., 2008.89

host enzymes, is created due to bidirectional ds replication, but is not helicoidal in structure. When it
becomes hydrolyzed by antibodies, it causes cell
death, which in turn opens the cell, exposing to
the immune system a new set of fresh antigens
and, therefore, perpetuating and maintaining the
vicious cycle in SLE. Figure 4 shows the possible
details of this interaction, causing ares in SLE in
response to viral infection or re-activation, with
corresponding clinical signs. The immune complexes, or unmethylated CpG motifs of hydrolyzed
DNA, sensitize transmembrane Toll-Like Receptor
9 (TLR9)90 on the surface of antigen presenting
cells (APCs), in this case B cells. This, in turn,
causes signaling to nucleus activating nuclear transcription factor kappa B (NF-kB)91 or MyD88
signaling with subsequent increase in anti-ssDNA
antibody synthesis through a genetic switch, the
steps of which are not yet clearly understood.92
This global concept is in agreement with the new
innate immunity scenario of autoimmune diseases,
in which the DNA-sensing cytosolic cellular proteins propagate the information on a viral DNA
sequence through a signal to TLR9, thereby avoiding the antigen presentation loop to T cells through
APC (B-lymphocyte or dendritic cells). This model,
at the same time, states that DNA cannot be presented to the immune system in the classical way,
since it is too large for the MHCI and/or II class
of molecules in both types of APCs. Rather, its
immunogenic role is to be sliced into smaller CpG
motifs (by DNases from the blood) which, as
unmethylated particles, sensitize transmembrane,
surface TLR9 to transduce the signal and information on the DNA sequence to the corresponding
transcription factors,91 and employ immunoglobulin gene machinery for anti-DNA autoantibody

Figure 4 Model of Parvovirus B19 Association with SLE II. Pavlovic, M., Kats, A., Shoenfeld, Y., 2008.32
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synthesis in the cells of B-series. These are not now

parvovirus B19 specic antibodies designed
towards viral capsids (IgG and IgM isotypes)
secreted as a result of primary infection (since
they have disappeared from plasma), but quite
new, hydrolytic, anti-ssDNA autoantibodies targeted against viral and probably even host
ssDNA (in replicating cells with inserted viral
DNA). So, the cells are going either to apoptosis
or necrosis, exposing to the activated immune
system a new array of autoantigens (especially
nuclear). Meanwhile, serum clearing mechanisms,
employed by regular DNases and newly synthesized
anti-ssDNA antibodies, are insucient to clean
apoptotic waste. This results in precipitation of
antibodies, and their complexes with DNA,
beneath basal membranes of small blood vessels,
including glomeruli. Increasing evidence of data
suggest that impairment in the uptake of apoptotic
cell debris is linked to autoimmunity.93 Thus, these
antibodies, the synthesis of which is triggered by
parvoviral infection and re-activation, trigger the
are, and can be both an early predictor and a
diagnostic sign of the are.94 In this way, they perpetuate and maintain the vicious cycle in SLE.

parvoviruses, strategically prepared for therapeutic

purposes could be employed in treatment. We
believe that development of the vaccine based on
inactivated capsid proteins (against viral proteins)
would be of the primary interest since they are the
most probably presented to the immune system in
the classical way, rendering T memory cells
informed and educated about their features critical
for T-lymphocytes activation. However, since none
of the vaccines based upon that concept did not
succeed so far,23,95 in accordance with innate
immunity scenario and B-cell memory for viral
DNA mentioned above,9094 this loop of viral
DNA recognition and memory storage within B
cells should not be ignored, and therefore considered on a larger scale of vaccine spectrum, including even attenuated virus.

Parvovirus B19 and SLE association: possible

impact and benefits

References

The primary impact of the above approach is that

physicians would be able to tailor specic therapies
for a disease that can have a multitude of symptoms
and causes. The patient will benet because their
disease and their immune response to the underlying disease will be understood in much greater
depth. Currently, nearly all patients are routinely
placed on global immunosuppressive regimens,
such as corticosteroids and non-specic chemotherapies. With computer-analyzed data sets of
genes or proteins from possible infectious agents
(especially parvovirus B19 as a center of interest)
and sophisticated analysis of the immune prole
concordant with each patient readily available to
the physician (microarrays at dierent levels),
appropriate therapeutic strategies can be employed.

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Summary
Should an agent, such as parvovirus, be shown to
be involved in eliciting the cyclical infection in a
signicant number of patients with lupus, would
it not be advisable to seek a vaccine to prevent
and perhaps someday treat the infection? For
example, human monoclonal antibodies against

Acknowledgment
The authors want to thank to Mr Alex Kotlarchyk
for his careful and helpful proof reading of the
article.

Lupus
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