Adenovirus infection after HSCT

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Adenovirus is pretty common in the general population, responsible for the common cold, sore throat, bronchitis, diarrhea and conjunctivitis. It is harmless in most instances and like the herpes virus, most of us remain latently infected.

During periods of immunosupression, however, the adenovirus can reactivate causing untoward trouble. The latter can range anywhere from organ-specific illnesses, such as pneumonia or diarrhea, to disseminated infections affecting a large portion of the body (with high viral counts). Fortunately, disseminated infections are rare, and although it comes with a hefty mortality rate of 26% post transplant. However, early detection and treatment can often counter this.

Below is a report of disseminated adenovirus infection in an individual with MS receiving HSCT. Their conditioning regimen was carmustine, etoposide, cytarabine, melphlan, and anti-thymocyte globulin. Over the post-transplant period, recovery was complicated by BK virus infection leading to hemorrhagic cystitis (bleeding from bladder infection) and respiratory syncytial virus of the upper respiratory tract – both suggesting susceptibility to infections. This was later followed by detection of adenovirus DNA in her samples. She was initiated on the anti-viral cidofovir early, but by day 45 had nausea, vomiting and diarrhea.

An endoscopic study of her gut revealed redness of the duodenum (Figure A below) and punctate lesions of the sigmoid colon (Figure B,C below), which later were identified as sites of adenovirus infection. At the time of the endoscopy she was lymphopaenic with a white cell count of 570/microL. She did, however, slowly improve with continued anti-viral treatment and equally there was a substantial improvement in the viral load by day 78.

Gut endoscope view of adenovirus infection

Fortunately, disseminated adenovirus infection is a rare complication of stem cell transplants, but should be suspected in individuals who have received anti-thymocyte globulin regimens (an infusion of antibodies against T cells), and in immunosuppressed individuals with positive blood viral load and new onset diarrhea.

Knowing what you are preventing is also very handy, and below is a list of infections that can occur after transplant.

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Infections after bone marrow transplant

Abstract

Transpl Infect Dis. 2019 Dec 27:e13238. doi: 10.1111/tid.13238. [Epub ahead of print]

Disseminated adenovirus infection after autologous stem cell transplant.

Kim NJ, Hyun TS, Pergam SA, Issaka RB.

Adenovirus is an infrequent but challenging viral complication of transplantation that is rarely reported after autologous stem cell transplant. We present a case of disseminated adenovirus infection in a woman who received an autologous stem cell transplant for treatment of multiple sclerosis. After presenting with post-transplant episodic diarrhea and viremia, endoscopic biopsies and immunohistochemical staining confirmed the diagnosis of disseminated adenovirus infection. Her symptoms and viremia resolved after treatment with cidofovir. This case demonstrates that a high-index of suspicion, a systematic clinical approach, and immunohistochemical tissue staining are necessary to diagnose disseminated adenovirus infection in an unexpected host.

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Neuro Doc Gnanapavan

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