SESSION TITLE: Infectious Disease Cases III
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Monday, October 28, 2013 at 04:15 PM - 05:15 PM
INTRODUCTION: Adenoviruses are DNA viruses most frequently associated with upper respiratory tract infections and less frequently pneumonia. Most illnesses are self-limiting, although fatal infections can occur in immunocompromised hosts and less commonly in healthy children and adults. We report a case of severe adenovirus infection leading to acute respiratory distress syndrome (ARDS) in an immunocompetent adult, treated successfully with lung-protective ventilation, cidofovir and intravenous immune globulin (IVIG).
CASE PRESENTATION: A 43 year-old woman presented to the emergency room with fever, cough and dyspnea. She was admitted and started on antibiotics for presumed community-acquired pneumonia. She rapidly became more dyspneic and confused, and an arterial blood gas revealed severe hypoxemia. She was transferred to the medical intensive care unit and intubated. A chest CT showed multifocal pneumonia (Fig 1). Polymerase chain reaction testing was positive for adenovirus serotype 3 with a plasma viral load of 762,772 copies/mL. She underwent bronchoscopy with bronchoalveolar lavage that was positive for adenovirus and negative for fungi, bacteria and other viral pathogens. A human immunodeficiency virus test was negative. Dose-reduced cidofovir and IVIG were administered and within 24 hours, the plasma viral load decreased to 119,724 copies/mL. On treatment day #3 it was 13,754 copies/mL, and by treatment day #7 it was less than 1,000 copies/mL (Fig 2). After starting cidofovir, her oxygenation improved, with a pre-treatment partial pressure of arterial oxygen to fraction of inspired oxygen (PaO2/FiO2) ratio of 115 increasing to 310 by treatment day #7 (Fig 2). She was extubated on hospital day #10. By hospital day #17 the plasma viral load was undetectable and she was discharged home. A repeat chest CT showed complete resolution of the multilobar consolidations.
DISCUSSION: The nucleotide analogue cidofovir has been used to treat adenoviral infections, though published data on the efficacy of both cidofovir and IVIG for treating such infections are limited, especially in immunocompetent hosts. Our case suggests that in immunocompetent adults who develop ARDS from adenovirus infection, the use of cidofovir and IVIG, in conjunction with established lung-protective ventilation strategies, can lead to improved oxygenation and reductions in plasma viral load.
CONCLUSIONS: Cidofovir and IVIG should be considered in immunocompetent patients with severe adenovirus-induced pneumonia who fail to respond to standard supportive care.
Reference #1: Neofytos D, et al. Treatment of adenovirus disease in stem cell transplant recipients with cidofovir. Biol Blood Marrow Transplant 2007; 13:74.
DISCLOSURE: The following authors have nothing to disclose: Avraham Sofer, Nicholas Arger, Michael Vest
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