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Case Reports in Transplantation
Volume 2013, Article ID 969186, 5 pages
http://dx.doi.org/10.1155/2013/969186
Case Report

Severe Necrotizing Adenovirus Tubulointerstitial Nephritis in a Kidney Transplant Recipient

1Division of Transplantation and Department of Pathology, Royal Oak, MI 48703, USA
2Oakland University William Beaumont School of Medicine, William Beaumont Hospital, Royal Oak, MI 48703, USA
3Beaumont Health System, Royal Oak, MI 48703, USA

Received 29 May 2013; Accepted 8 July 2013

Academic Editors: P. A. Andrews, A. Beiras-Fernandez, and I. Engelmann

Copyright © 2013 Ravi Parasuraman et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Adenoviruses (AdV) are emerging pathogens with a prevalence of 11% viruria and 6.5% viremia in kidney transplant recipients. Although AdV infection is common, interstitial nephritis (ADVIN) is rare with only 13 biopsy proven cases reported in the literature. We report a case of severe ADVIN with characteristic histological features that includes severe necrotizing granulomatous lesion with widespread tubular basement membrane rupture and hyperchromatic smudgy intranuclear inclusions in the tubular epithelial cells. The patient was asymptomatic at presentation, and the high AdV viral load (quantitative PCR>2,000,000 copies/mL in the urine and 646,642 copies/mL in the serum) confirmed the diagnosis. The patient showed excellent response to a combination of immunosuppression reduction, intravenous cidofovir, and immunoglobulin therapy resulting in complete resolution of infection and recovery of allograft function. Awareness of characteristic biopsy findings may help to clinch the diagnosis early which is essential since the disseminated infection is associated with high mortality of 18% in kidney transplant recipients. Cidofovir is considered the agent of choice for AdV infection in immunocompromised despite lack of randomized trials, and the addition of intravenous immunoglobulin may aid in resolution of infection while help prevention of rejection.