A RARE CASE OF DISSEMINATED ADENOVIRUS CAUSING SEPTIC SHOCK WITH MYCOPLASMA COINFECTION SUCCESSFULLY TREATED WITH CIDOFOVIR

Abstract

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: We present a rare case of refractory septic shock secondary to disseminated adenovirus co-infected with Mycoplasma that was successfully treated with cidofovir. CASE PRESENTATION: A healthy 7-year-old male presented with fever and cough of 10 days. He was diagnosed with Mycoplasma pneumoniae (Mp) based on cold agglutinin screen and was given azithromycin. With no improvement in symptoms after two days, chest x-ray revealed left lower lobe pneumonia, Biofire showed adenovirus (ADV) with negative Mp, and urinalysis showed 2+ protein and 3+ blood. He was admitted to the hospital, given ceftriaxone, and started on oxygen via nasal cannula for hypoxia. He rapidly deteriorated, developed left-sided pleural effusion requiring chest tube insertion, and had more difficult oxygenation; so he was transferred to the Pediatric Intensive Care Unit. Within 24 hours, he developed respiratory failure and pressor-dependent shock requiring veno-venous extracorporeal membrane oxygenation (ECMO). Antibiotics were escalated. With progression of disease, the decision was made to initiate cidofovir therapy (5mg/kg once) that day despite known proteinuria and renal insufficiency. He developed renal failure requiring initiation of continuous renal replacement therapy (CRRT) the day after ECMO started. An Mp titer was sent showing positive IgG and elevated IgM (4933 U/mL), so azithromycin was restarted. He was also started on steroids for concern for adrenal insufficiency. Initial ADV viral load was >2million copies. After 5 days a second ADV PCR was obtained showing 942 copies, so a second cidofovir dose (1mg/kg once) was given. He was able to be decannulated on day 7 to a conventional ventilator. Two weeks later, he had an undetectable viral load and was on room air. Renal support was weaned off completely with eventual recovery of function to baseline. DISCUSSION: ADV is ubiquitous, with some genotypes causing outbreaks of life-threatening viral pneumonia even in immunocompetent adults. Reports of severe ADV pneumonia are much less common in immunocompetent children: disseminated disease occurs in less than 2% and is very rare in those older than 3 years (two published reports in adults and children above the age of 3). It is possible that Mp served as an immune modulator for ADV to cause such severe disease. CONCLUSIONS: To our knowledge, this is the first co-infection with ADV and Mp described in critically ill children; Mp has been described as coinfection for measles and pertussis. A study of the ELSO registry from 1998-2009 showed that only 38% of children on ECMO for ADV infection survived to discharge, and that survival was less common among those requiring dialysis (17%); however, this patient had good acute outcomes with the use of cidofovir. Reference #1: Munoz FM, Piedra PA, Demmler GJ. Disseminated adenovirus disease in immunocompromised and immunocompetent children. Clin Infect Dis. 1998;27(5):1194-200. Reference #2: Jeong E, Maslyanskaya S, Coupey SM. Disseminated adenovirus disease presenting as septic shock in an immunocompetent pubertal girl. Infect Dis Clin Pract 2018;26: e25–e27. Reference #3: Prodhan P, Bhutta AT, Gossett JM, Stroud MH, Rycus PT, Bratton SL, Fiser RT. Extracorporeal Membrane Oxygenation Support Among Children with Adenovirus Infection: A Review of the Extracorporeal Life Support Organization Registry ASAIO Journal 2014; 60:49–56. DISCLOSURES: No relevant relationships by Ashley Choe, source=Web Response No relevant relationships by William Dalzell, source=Web Response No relevant relationships by Kathryn Kocher, source=Web Response No relevant relationships by Bianca Rad, source=Web Response