Immunocompromised patients are at risk for serious complications.

Takeaways:

• Adenovirus, which typically presents as a febrile respiratory illness for 1 week, is most commonly found in infants, children, and immunocompromised individuals.
• Adenovirus can be transmitted via the direct fecal-oral route, aerosolized droplets, or exposure to infected tissue or blood.
• Current recommendations to prevent the spread of adenovirus include frequent handwashing with soap and water, avoiding touching mucous membranes with unwashed hands, and limiting close contact with people who are ill.

SAM RUSSO,* age 58, arrives in the emergency department and reports having a fever and feeling “worn out” for 3 days. On physical exam, Mr. Russo appears febrile, congested (as evidenced by nasal drainage and cough), and fatigued. He says he’s nauseated but hasn’t vomited. On admission to a medical unit, Mr. Russo’s vital signs are heart rate (HR) 102 beats per minute (bpm), blood pressure (BP) 103/64 mmHg, respiratory rate (RR) 17 breaths/minute, and temperature 102° F (38.9° C).

History and assessment hints

Dale, Mr. Russo’s nurse, notes that initial laboratory results show blood glucose 125 mg/dL (normal 70-99 mg/dL), sodium 132 mmol/L (normal 135-145 mmol/L), lactate 0.9 mmol/L (normal 0.6-2.2 mmol/L); the basic respiratory viral panel (RVP) is negative for influenza. An electrocardiogram shows sinus tachycardia. Mr. Russo’s provider suspects upper respiratory viral illness and orders a bolus of normal saline to help restore intracellular hydration, acetaminophen as an antipyretic, and a chest X-ray to rule out lung disease. Differential diagnoses include bronchitis, influenza, and pneumonia.

Clinical management

Mr. Russo’s respiratory status progressively deteriorates, as evidenced by mild wheezing, fatigue, myalgias rigors, and abnormal vital signs (HR 110 bpm, BP 96/60 mmHg, RR 20 breaths/minute, and temperature 103° F [39.4° C]). Dale immediately notifies the provider. A repeat chest X-ray shows right lower lobe atelectasis. Mr. Russo is treated for community acquired pneumonia and prescribed azithromycin and ceftriaxone. Mr. Russo’s fever persists, and he becomes lethargic. The provider adds vancomycin and moxifloxacin. Overnight, Mr. Russo develops pleuritic chest pain, and his oxygen saturation falls to 90%, requiring 5 liters of oxygen by nasal cannula.

When Mr. Russo’s oxygen saturation drops to 82%, Dale calls the rapid response team (RRT). Mr. Russo is placed on a 100% nonrebreather mask, given a nebulizer treatment, and transferred to the intensive care unit. A chest X-ray reveals worsening bilateral consolidation and crackles. The intensivist suspects acute respiratory distress syndrome. Mr. Russo is given a trial of furosemide to offload extra fluid and a computed tomography chest scan is negative for pulmonary embolism, but shows bibasilar mucous plugging. The extended RVP results are positive for adenovirus.

Mr. Russo becomes hemodynamically unstable (with impending respiratory failure) and is intubated. A bronchoscopy reveals copious frothy, grayish secretions. He is started on propofol, oseltamivir, boluses of saline, and vasopressors. Although he remains hospitalized for a month, Mr. Russo is eventually discharged home.

Education

Adenovirus typically presents as a febrile respiratory illness for 1 week. It can cause mild to severe, including pharyngitis, conjunctivitis, bronchitis, malaise, head ache, abdominal pain, cystitis, and pneumonia. Adenovirus is most commonly found in infants, children, and immunocompromised individuals. It’s more common in males. A vaccine developed in the 1970s is approved for members of the U.S. military between ages 17 and 50 years.

The overall prognosis of adenovirus is good, and severe morbidity and mortality are rare; however, mortality rates have been as high as 70% in the immunocompromised population. Adenovirus can be transmitted via the direct fecal-oral route, aerosolized droplets, or exposure to infected tissue or blood.

Most cases of adenovirus are self-limiting, and current therapy is symptom treatment. No evidence-based guidelines are available; however, several drugs, such as cidofovir, ribavirin, ganciclovir, and vidarabine, have been used to treat the virus. Current recommendations to prevent the spread of adenovirus include frequent handwashing with soap and water, avoiding touching mucous membranes with unwashed hands, and limiting close contact with people who are ill.

*Names are fictitious.

Jennifer Schieferle Uhlenbrock is a clinical educator at St. David’s South Austin Medical Center in Austin, Texas.

Selected References

Centers for Disease Control and Prevention. Adenoviruses. 2018. cdc.gov/adenovirus/hcp/index.html

Gompf S. Adenovirus. 2018. emedicine.medscape.com/article/211738-overview