Case # 1. A 65 year old, CMV D+/R- kidney transplant recipient receiving mycophenolate and prednisone presented with 1 month h/o hematuria and progressive renal failure secondary to adenovirus nephritis.
From: https://www.google.com/search?q=adenovirus+electron+microscopy&source=lnms&tbm=isch&sa=X&ei=RP_8U9GlGsO0yAS5lICQCQ&ved=0CAgQ_AUoAQ&biw=1920&bih=943#facrc=_&imgdii=_&imgrc=jysh9OgcvqH5YM%253A%3BqFxYXFIK5hJFGM%3Bhttp%253A%252F%252Fwww.virology.net%252Fbig_virology%252FEM%252FAdeno-FD.jpg%3Bhttp%253A%252F%252Fwww.virology.net%252Fbig_virology%252FBVDNAadeno.html%3B979%3B964
1. Know the different clinical manifestations of adenovirus infection in immunocompromised patients: pneumonia (including necrotizing pneumonia and diffuse alveolar damage), gastroenteritis, hepatitis, hemorrhagic cystitis, interstitial nephritis, and meningoencephalitis. Among immunocompetent patients, adenovirus infection usually manifests as nonspecific upper respiratory tract illness, gastroenteritis, pharyngo-conjunctival fever, and epidemic keratoconjunctivitis.
2. Kidney transplant recipients who developed adenovirus graft-nephritis had better survival compared to other transplant recipients who developed native-kidney adenovirus nephritis according to one case series.
3. Histopathologic examination of a biopsy specimen is the gold standard for diagnosing invasive adenoviral infection. In situ hybridization is utilized to confirm the presence of the virus in tissues. Cells infected with adenovirus have large nuclei with basophilic inclusions and a thin rim of cytoplasm (so called smudge cells). Granulomatous formation is often observed. Adenovirus PCR can also be used but it should always be correlated with histopathology and with the clinical presentation to distinguish between asymptomatic infection and disease.
4. In immunosuppressed patients, the cornerstone of management for invasive adenovirus infection is supportive care and reduction of immunosuppression (read here). If treatment is desired, cidofovir is likely the best antiviral agent to use. Probenecid is used together with cidofovir to block active renal tubular secretion of cidofovir, thereby, preventing the development of nephrotoxicity. Aggressive hydration with fluid is recommended with cidofovir use.
5. In patients who develop adenovirus nephritis, concurrent use of probenecid is not recommended to ensure increased drug delivery to the site of infection.
Case # 2. A 6 year old child presented with 1 day of fever, diffuse maculopapular rash, and knee pain after returning from a 1 month trip to Puerto Rico a few days prior to admission secondary to chikungunya fever.
From: http://www.cdc.gov/chikungunya/images/maps/CHIK_Americas_Map-081214.jpg
1. Chikungunya ("that which bends up" in Tanzanian), was first described from an outbreak of fever in Tanzania in 1952.
2. It is characterized by fever that lasts for 3-5 days followed 2-5 days later by polyarthralgia (hands > wrists > ankles) that can sometimes be extremely debilitating. A diffuse maculopapular rash (which is pruritic in up to 50%) occurs in 40-75% of patients. After the acute illness, up to 60% of patients can have persistent joint pains for up to 36 months.
3. The closest differential diagnosis is dengue fever as it is also transmitted by the Aedes mosquito vector. The main difference between dengue and chikungunya fever is that myalgia and polyarthralgia are virtually present in all chikungunya patients while they are uncommon findings in dengue patients. Thrombocytopenia is also more severe in dengue fever.
4. If the illness is suspected early (<5 days), obtaining plasma for viral PCR testing is the best method to diagnose chikungunya fever. Plasma viral-specific IgM and neutralizing antibodies are usually checked after 5 days of illness. Samples should be sent to the state laboratory or the CDC.
5. Outbreaks have traditionally been localized in Africa, Asia, and Europe but in December 2013, for the first time, chikungunya virus was found in the Americas. At present, there is an outbreak of chikungunya fever in the Caribbean. In July 2014, 2 patients from Florida who had not traveled outside of the US were diagnosed with chikungunya fever as reported by the CDC (read here).
Case # 3. A 21 year old woman from India develops fever, myalgia, diarrhea, severe leucopenia/thrombocytopenia, rhabdomyolysis, hepatitis, and multi-organ failure secondary to ciprofloxacin-resistant Salmonella enterica serotype Typhi infection (typhoid fever)
1. Tyhpoid fever can cause bone marrow suppression either by direct infiltration or induction of the macrophage activating system (hemophagocytic syndrome). Salmonella in the bone marrow can also lead to granuloma formation.
2. Alternative antibiotics used for the treatment of ciprofloxacin-resistant Salmonella include: ceftriaxone, azithromycin, or chloramphenicol. Other agents that may be active include imipenem and trimethoprim-sulfamethoxazole.
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