Case Report

Fatal Adenovirus Infection in an Immunocompetent Adult A Case Report

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Introduction

Adenoviruses are associated with a variety of clinical syndromes and cannot be diagnosed based upon clinical criteria alone. Among children it can cause endemic respiratory disease, gastroenteritis and conjunctivitis. 1 2  Most of these infections are self limited, with severe or disseminated disease confined to immunocompromised patients, like patients with AIDS and transplant recipients. 3 4  Among healthy adult’s severe morbidity and mortality due to adenovirus infection is distinctly unusual. 5  In immunocompetent adults it gained attention initially in 1950s and 1960s, prior to development of vaccine, due to epidemic of adenovirus serotypes 4 and 7 in military recruits. 6  Its ability to cause severe disease in healthy adults has become major concern recently due to fulminant cases out breaks including two deaths in military recruits reported by Center of Disease Control. 7  We describe a well documented fatal case of adenovirus pneumonia in an immunocompetent young male, and we discuss potential clinical features of this rare but life threatening disease. It will underscore the need to consider this infection early, even in immunocompetent adults who do not respond to usual treatment.

Case Report

A healthy 35 year-old male presented with a four-day history of severe abdominal pain, vomiting, watery diarrhea, fever, chills and a two-day history of dry cough and dyspnea. He was febrile with a tender abdomen. An CT scan was negative for appendicitis. His initial chest examination revealed bilateral diffuse wheezes and left base crackles. His respiratory rate was 16 and he was saturating 100% on room air. Laboratory workup was significant for a white blood cell count (7,100/mm3), thrombocytopenia (81000/U), elevated SGPT (48IU/L) SGOT (122IU/L) and creatinine (1.5mg/dl). Chest X-ray showed left lower lobe consolidation.

Despite ceftriaxone and levofloxacin, he remained febrile. Blood, stool and sputum cultures were negative. HIV and mycoplasma antibodies, and urine legionella antigen were negative. On day 4 his vomiting and diarrhea resolved but he remained febrile. His CPK was 7415 IU/L with 16% MB fraction. EKG remained normal. Chest X-ray showed bilateral infiltrates and left pleural disease.

On day six he became short of breath. His chest CT chest showed a left lower lobe and a right upper lobe infiltrates.

On day eight, he was intubated for worsening hypoxia, had several episodes of bradycardia and died. Autopsy lung cultures grew adenovirus.

Discussion

Severe adenovirus respiratory infections in immunosuppressed individuals have been well described but few cases have been reported in immunocompetent adults. 8 9  This case illustrates some of the typical features of adenovirus pneumonia, which if recognized earlier, could prompt a more timely diagnosis. These features include: 1. no positive cultures and no response to treatment for atypical pneumonias, 2. one-week presentation with dyspnea, cough, high-grade fever, rhonchi or wheezes which rapidly progresses to respiratory failure and shock 5 7 10  3. chest x-ray with a focal infiltrate, which is unusual for most viral pneumonias. 3 5 7 10  In addition our case presented with gastroenteritis, which has also been reported with adenovirus pulmonary infections, as well as myocarditis, another feature of adenovirus infections but not previously described with pneumonias.

Nasopharyngeal aspirate or swab, throat swab, sputum or tissue cultures are the most sensitive and specific method for detecting adenovirus. Recent infection can be documented by assay of paired acute and convalescent sera for adenovirus specific antibodies. Most cases of adenovirus are self-limited. Currently no antivirals are approved for treatment. Cidofovir has been shown effective in some cases, although in vitro resistance has occurred. 11

References

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  2. Hierholzer JC. Adenoviruses. In: Lennette EH, Lennett DA, Lennette ET, eds. Diagnostic procedures for viral, rickettsial, chlamydial infection. 7th ed. Washington, DC: American Public Health Association, 1995.

  3. La Rosa AM, Champlin RE, Mirza N, Gajewski J, Giralt S, Rolston KV, et al.Adenovirus infections in adult recipients of blood and marrow transplants. Clin Infect Dis 2001; 32:871-6.

  4. Shintaku M, Nasu K, Ito M. Necrotizing tubulo-interstitial nephritis induced by adenovirus in an AIDS patient. Histopathology 1993; 23:588-90.

  5. Klinger JR, Sanchez MP, Curtin LA, Durkin M, Matyas B. Multiple cases of life-threatening adenovirus pneumonia in a mental health care center. Am J Respir Crit Care Med 1998; 157: 645-649

  6. Buescher EL. Respiratory disease and the adenoviruses. Med Clin North Am 1967;51: 769-779.

  7. From the Centers for Disease Control and Prevention. Two fatal cases of adenovirus-related illness in previously healthy young adults– Illinois, 2000. JAMA 2001, 286:782-3.

  8. Zarraga AL, Kerns FT, Kitchen LW. Adenovirus pneumonia with severe sequelae in an immunocompetent adult. Clin Infect Dis 1992; 15:712-3.

  9. Komshian SV, Chandrasekar PH, Levine DP. Adenovirus pneumonia in healthy adults. Heart Lung 1987; 16:146-50.

  10. Barker JH, Luby JP, Dalley AS, Bartek WM, Burns DK, Erdman DD. Fatal type 3 adenoviral pneumonia in immunocompetent adult identical twins. Clin Infect Dis 2003; 37:e142-e146

  11. Taylor, DL, Jeffries, DJ, Taylor-Robinson, D. The susceptibility of adenovirus infection to the anti-cytomegalovirus drug, ganciclovir (DHPG). FEMS Microbiol Lett 1988; 49:337.