INTRODUCTION

TOP ABSTRACT INTRODUCTION REFERENCES

Adenoviruses are common pathogens associated with severe infections in immunosuppressed hosts, and particularly in patients with secondary immunodeficiencies, such as transplant recipients, cancer patients undergoing immunosuppressive chemotherapy, and HIV-infected patients (1). The outcome is usually fatal unless the cause of immunosuppression can be interrupted. We report a case of an adult AIDS patient with adrenovirus pneumonia treated with intravenous ribavirin.

	CASE REPORT

A 38-year-old man was admitted in October 1995 with fever and thoracic pain. This patient tested HIV-positive in 1984 and subsequently developed microsporidiosis with cholangitis and cytomegalovirus retinitis. Upon admission his therapy included cotrimoxazole, fluconazole, rifabutin, ganciclovir, zidovudine, lamivudine, and daily parenteral nutrition. Examination on admission disclosed fever (40° C) and dry cough. Chest radiograph and computed tomography (Figure 1) showed multiple bilateral nodular opacities. Laboratory data included a hemoglobin of 8 g/dl, a white blood cell count of 3,100/mm³ with 2,400 polynuclear neutrophils. The CD4 cell count was 5/mm³. Blood cultures for bacteria were sterile. Fiberoptic bronchoscopy with bronchoalveolar lavage showed lymphocytosis and yielded no pathogens. Surgical pulmonary biopsy of right nodules showed throughout the pulmonary parenchyma foci of necrotizing pneumonitis containing numerous cells with "smudged" basophilic nuclear inclusions. These inclusions occupied the entire nucleus and were typical of adenovirus. Immunocytology with adenovirus antibody was positive. In addition, search for other pathogens was negative (Ziehl, Gram's, Grocott, Warthin-starry, May-Grunwald-Giemsa stains, and immunofluorescence for cytomegalovirus and Pneumocystis carinii). Treatment with intravenous ribavirin was initiated at 3 g/d for 4 d, then 1.5 g/d for 10 d. Within 48 h of ribavirin therapy, the patient's condition improved markedly. Oral ribavirin was maintained for 1 mo, then stopped because of anemia. No other anti-infective therapy was administered. Chest X-ray showed marked improvement at day 8 and computed tomography (Figure 2) showed almost complete resolution of the parenchymal process at day 30. Two blood transfusions were required during ribavirin therapy because of severe anemia. Eight months later, the patient was readmitted with high fever, breathlessness, and cachexia. Chest radiograph showed multiple nodular opacities. There were multiple hyperechogen hepatic lesions on abdominal ultrasonography. Bronchoalveolar lavage was not performed, and the patient was treated once more with intravenous ribavirin. Despite apyrexia, the pulmonary and general condition worsened. The patient died 4 d later. An autopsy was not performed.

View larger version (93K): [in this window] [in a new window]   Figure 1.   Computed tomography showing nodular and alveolar densities with air space consolidated in both lungs.

View larger version (103K): [in this window] [in a new window]   Figure 2.   Computed tomography at day 30 of ribavirin treatment showing almost complete resolution of the active parenchymal process.

Ribavirin is a broad-spectrum purine nucleoside analog antiviral agent that is structurally related to guanosine. It has in vitro activity against a wide range of DNA and RNA viruses, including adenoviruses. Seven cases of successful treatment of adenovirus infection with ribavirin have been reported: hemorrhagic cystitis (2); nephritis (5), gastroenteritis (6), pneumonia (7), and disseminated infection (8). Most of them concerned children and bone marrow recipients. No patient was HIV-infected. As in most cases, the response to therapy was dramatic, with the rapid resolution of fever and rapid improvement of pneumonia. Hemolytic anemia is the most significant side effect and may be dose-limiting, especially in patients who have preexisting anemia and hematotoxic drugs as our patient had. Furthermore, the doses administered to our patient were twice the dosage usually given. Although no autopsy was performed, the cause of death was most likely due to the relapse of the adenovirus pneumonia associated with hepatitis. This case report raises several points: (1) adenoviruses may cause severe lung disease in HIV-infected patients, and definitive diagnosis is established by biopsy; (2) ribavirin is effective, as shown by the dramatic improvement during treatment; and (3) maintenance therapy should be considered to avoid life-threatening relapse.