Adenovirus

The symptomatic patient developed low-grade fever, lymphopenia, hematuria, pyuria and elevated creatinine (1.69 mg/dl compared to 1.15 mg/dl one month prior to onset of symptoms) with tenderness over the allograft with pyelonephritis at 4 weeks posttransplant. CT scan showed progressive perinephric stranding and allograft edema. Serum HAdV nucleic acid testing at approximately 5 weeks posttransplant was positive at 6 x 10(6) copies/ml. Core biopsy of the allograft showed tubular necrosis and "smudge" chromatin with histologic findings consistent with adenovirus. He responded to cidofovir and probenecid with improvement in renal function. The second kidney recipient was asymptomatic. The donor heart and lungs were transplanted to separate patients who were asymptomatic and were not tested for the presence of HAdV neutralizing antibodies or PCR. In references listed below, 3 patients were described by Koslowski T, et al with donor derived HAdV infection, one donor with 2 recipients, with hemorrhagic cystitis and nephritis at 11 days requiring transplant nephrectomy in one patient and the second with dysuria and positive urine for AdV at 19 days and recovery of renal function when immunosuppression was decreased. The third patient from a separate donor developed delayed graft function requiring hemodialysis and negative biopsy for viral injury and gradual improvement in renal function. Creatinine increased to 5.3 mg/dl requiring repeat kidney biopsy consistent with HAdV, acute tubular necrosis with microabscesses and required transplant nephrectomy. Report of two patients by Dawood et al showed both patients with disseminated adenovirus, one at 4 weeks posttransplant, the second at 27 months posttransplant, both recovering with Cidofovir and IVIG. A report by Rady et al described a case of adenovirus nephritis presenting 6 weeks posttransplant, recovering with lowering of immunosuppression and IVIG. A review of 17 kidney transplant recipients in Thailand with adenovirus infection between 2007 - 2010 reported 76.5% of cases developing within 3 months of transplantation with symptoms ranging from fever and dysuria to allograft dysfunction.