Case Presentation: A 32-year-old South Asian woman with history of IgA nephropathy complicated by end stage renal disease status post renal transplant (CMV/EBV positive), latent tuberculosis infection, C. Diff colitis, and recurrent urinary tract infections presented with two days of fevers and diarrhea. One week prior to admission she was seen at a local ED for dysuria and was empirically treated with cefpodoxime for presumed UTI. Two days following completion of cefpodoxime, she began to experience profuse non-bloody diarrhea accompanied by fevers, chills, dysuria, myalgias and arthralgias. During her admission, she had fevers up to 101.3°F with diaphoresis. Laboratory tests were notable for serum creatinine 1.5 (from baseline 1.0), and no leukocytosis, neutrophilia or bandemia. Her urinalysis showed cloudy urine with large blood, small protein, large leukocyte esterase, greater than 100 red blood cells (RBCs), greater than 100 white blood cells (WBCs) and few bacteria. Infectious work-up including blood, urine, and stool cultures were all negative, as were whole-body CT scans, colonoscopy, and gallium scan. She was treated with vancomycin and piperacillin-tazobactam. She was eventually found to have an adenovirus viral load of 219,000 despite negative viral cultures. She was treated with Brincidofovir which resulted in cessation of her fevers, diarrhea and viremia.
Discussion: Adenovirus in solid organ transplant is very rare and deadly. Though adenovirus most commonly causes respiratory illness, it can also cause gastroenteritis, cystitis, conjunctivitis and less often neurological disease. Adenovirus has severe consequences, specifically in patients with compromised immune systems. Currently, the only FDA approved treatment for disseminated adenovirus is Cidofovir, a highly nephrotoxic medication. Until recently, the only treatment for patients with renal impairment and/or transplanted kidneys was supportive care. Brincidofovir, an investigational, lipophilic formulation of cidofovir without its nephrotoxic properties is currently showing great promise at clearing adenovirus in this special patient population.
Conclusions: Disseminated adenovirus in solid organ transplant recipients is an uncommon and deadly condition. It can mimic other infections like influenza, C. Diff infection or gastroenteritis. Clinicians should remain vigilant for this disease, particularly in immunocompromised patients with persistent fevers, diarrhea and negative infectious work-ups. Clinicians should also remain vigilant for novel therapies that are showing great promise in decreasing mortality.