Rare Productive Adenovirus Infection of a Renal Allograft

51 year old male 8 months status post kidney/pancreas transplant for type I diabetes.  Presents with a 2 week history of gross hematuria, fevers, and Cr increase to 2.8 (baseline 1.1).  Renal biopsy performed to rule out acute cellular rejection/infection.

Geographic necrotizing granulomatous tubulointerstitial nephritis.

High power shows prominent tubular destruction with a histiocyte and neutrophil rich infiltrate.  Rare irregular nuclear viral inclusions are noted in the right lower quadrant.

Immunohistochemistry for Adenovirus confirms the diagnosis.

Adenovirus infection in the renal allograft is very rare, but usually occurs early after transplant (first 3 months).  Clinically significant adenovirus infection typically involves the urothelium and causes hemorrhagic cystitis, primarily in immunosuppressed patients.  Hematuria is a common presenting symptom.  Serotype 11 is most often associated with clinical disease.

The histology is characterized by intranuclear viral inclusions in the tubular epithelial cells, severe tubular destruction with necrosis, marked interstitial granulomatous inflammation, and focal interstitial hemorrhage +/- RBC casts. 

Treatment for adenovirus nephritis is not well defined.  Different strategies have involved IVIG, decreased immunosuppression, and anti-viral agents.

Despite a lack of standardized treatment, the prognosis is good with graft loss rare. 

PubMed Reference