Fatal adenovirus meningoencephalitis in end stage renal disease patient

Abstract

Background: Severe disseminated adenovirus infections that presented with severe pneumonia in respiratory failure, encephalitis or septicemic shock causes high mortality in immunocompromised patients. We reported a case ofadenovirus encephalitis in an end stage renal disease (ESRD) who presented with seizure, subsequently adenovirus DNA was detected from his cerebrospinal fluid with typical findings on electroencephalography (EEG). It highlights the need for consideration of adenovirus as cause of encephalitis. Case Description: A 66 y old gentleman with (ESRD) on regular hemodialysis was initially admitted to another hospital for 1w. He was found unconscious in the bathroom at home and subsequently developed tonic-clonic seizure prior to arrival to hospital. Patient had fever and productive cough for three days prior. On arrival to emergency department, he was intubated in view of low Glasgow coma scale (GCS) (E1V2M3). Neurological examination revealed normal tone. Contrast enhanced Computer Tomography (CT) of brain revealed multifocal old infarct with small right parieto-temporal scalp hematoma. Cerebrospinal fluid (CSF) showed high protein 871 ng/L and normal glucose ratio with elevated white cell count 10 cells/mm3 predominantly lymphocytes. CSF cryptococcal antigen and Indian Ink were negative and other cultures had no growth. He was treated as meningoencephalitis and started on intravenous ceftriaxone 2 g BD and IV acyclovir 250 mg OD Second lumbar puncture repeated on day 9 on transfer to our hospital of illness in view of no clinical improvement showed elevated opening pressure 22 cm H2O. CSF analysis revealed elevated protein 510 ng/L with adenovirus PCR was positive (4.5 log 10 DNA copies/ml). (EEG) revealed periodic lateralized epileptiform discharges. No other bacterial or fungal pathogen was identified s and tuberculous PCR was negative Intravenous cidofovir was initiated. However, his condition continued to deteriorate and succumbed 5 d following first dose of cidofovir (day 17 of hospitalisation). Discussion: This case highlights the need of consideration of adenovirus meningoencephalitis and illustrates the potential fatal disease in dialysis dependent renal disease patient. The initial diagnosis in this case is challenging as the initial clinical presentation is mimicking severe bacterial infection or septicaemia. Conclusion: Adenovirus meningoencephalitis is a rare but fatal manifestation of severe adenovirus infection with mortality rate up to 39%.