Adenovirus Hepatic Abscess: A Novel Source of Fever of Unknown Origin in a Pediatric Liver Transplant Recipient

Excerpt

A 10-year-old girl with biliary atresia who underwent orthotopic liver transplant July 2012 was initially evaluated by our institution 1 year after transplant with 2 weeks of daily fevers up to 104 °C. She had associated fatigue, abdominal pain, and anorexia, but denied emesis, changes in bowel movements, dysuria, cough, rash, or rhinorrhea. She was fully vaccinated pre-transplant and had no animal exposures or travel outside of the USA. Her post-liver transplant course was complicated by an episode of acute rejection 1 month after transplant, as well as by hepatic artery stenosis. Her immunosuppressive medications were tacrolimus and sirolimus, with supratherapeutic serum concentrations requiring dosage reduction several weeks prior to admission. Hospital admission laboratories were notable for mild leukopenia (white blood cell count 2.2), elevated C-reactive protein (16.9, normal <0.2), aspartate aminotransferase (AST) 76, alanine aminotransferase (ALT) 91, and gamma-glutamyl transferase (GGT) 69. Urinalysis and lipase were normal. Initial infectious evaluation was negative for Epstein–Barr virus (EBV) or cytomegalovirus (CMV) in serum as detected by polymerase chain reaction (PCR), and for bacterial culture, Clostridium difficile toxin, and ova and parasites in stool. An abdominal magnetic resonance imaging (MRI) demonstrated a 3.7 cm × 2.5 cm × 2.4 cm fluid collection in the liver, concerning for pyogenic abscess (Fig. 1a, b). Interventional radiology performed a computed tomography (CT)-guided drainage of the fluid collection as well as a liver biopsy (Fig. 2). Serum adenovirus PCR was then noted to be significantly elevated at 21,700 viral copies/milliliter (mL). Liver tissue surrounding the aspirated fluid collection showed hepatic necrosis with positive immunohistochemical staining for adenovirus (Fig. 3). The liver biopsy showed portal inflammation with granulomata, but negative adenovirus immunohistochemical staining. PCR of urine for adenovirus was positive, stool adenovirus antigen was negative, and respiratory viral PCR testing was negative for adenovirus. An extensive infectious work-up was performed and was negative, including hepatitis A, B, and C serologies, bartonella titers, coccidioidomycosis titers, brucella antibody, coxiella titers, histoplasma antigen, toxoplasmosis antibody, HIV western blot, rapid plasma reagin (RPR), and QuantiFERON^®-TB gold. Bacterial and fungal cultures of the blood and the liver abscess aspirate were negative. Liver tissue fungal stains and acid-fast bacilli stains were also negative.

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