CASE REPORT |
https://doi.org/10.5005/jp-journals-10081-1438 |
A Case Report of Adenoviral Pneumonia with Splenic Infarction
1,2Department of Pediatric Intensive Care Unit, Rainbow Children’s Hospital, Secunderabad, Telangana, India
3Department of Pediatric Hematology and Oncology and BMT, Rainbow Children’s Hospital, Secunderabad, Telangana, India
Corresponding Author: Preetham K Poddutoor, Department of Pediatric Intensive Care Unit, Rainbow Children’s Hospital, Secunderabad, Telangana, India, Phone: +91 9848030734, e-mail: drpreethamp@hotmail.com
Received: 28 May 2024; Accepted: 30 June 2024; Published on: 05 November 2024
ABSTRACT
Human adenovirus (HAdv) infections are very common in children under 5 years of age and can present with varied manifestations including respiratory, gastrointestinal, neurological, cardiac, hematologic, and genitourinary symptoms. We report a 12-year-old boy with HAdv pneumonia who experienced fever remission by the 3rd week of illness. However, he subsequently developed a relapse of fever spikes along with left hypochondriac pain. Upon evaluation, he was found to have splenic infarction (SI). To the best of our knowledge, this is the first case report of adenoviral infection associated with SI.
Keywords: Adenoviral pneumonia, Case report, Human adenovirus, Splenic infarct
How to cite this article: Siddhartha G, Poddutoor PK, Vaddadi S. A Case Report of Adenoviral Pneumonia with Splenic Infarction. Pediatr Inf Dis 2024;6(4):138–139.
Source of support: Nil
Conflict of interest: None
Patient consent statement: The author(s) have obtained written informed consent from the patient’s parents/legal guardians for publication of the case report details and related images.
INTRODUCTION
Human adenoviruses (HAdV), members of the Adenoviridae family, are medium-sized viruses (70–100 nm) with a double-stranded deoxyribonucleic acid (DNA) genome.1 HAdv infections are very common in children under 5 years of age, with a peak incidence in those under 2 years old.2
Viral infections are known to cause disturbances in all aspects of the coagulation cascade—primary hemostasis, coagulation, and fibrinolysis. As a result, both thrombotic and hemorrhagic events can occur.3 We report a case of a 12-year-old boy with HAdv pneumonia complicated by splenic infarction (SI).
CASE DESCRIPTION
A 12-year-old boy presented with fever and cough of 2 weeks’ duration. His past medical history was uneventful except for focal epilepsy with impaired awareness, for which he had been on lacosamide, perampanel, and clobazam for the past few years. On presentation, he was hemodynamically stable with bilateral crepitations and wheezing on auscultation. Laboratory tests revealed a white cell count of 7120 cells/mm3, C-reactive protein >200 mg/L, erythrocyte sedimentation rate (ESR) 60 mm/hour, and procalcitonin of 3.63 ng/mL. Chest radiograph showed haziness in bilateral upper lobes. He was initially treated with piperacillin–tazobactam for presumed bacterial pneumonia. A computed tomography (CT) scan of the chest confirmed consolidation in the bilateral upper lobes. Bacterial cultures of blood and urine were negative. Sputum for acid-fast bacilli and Mantoux test were also negative. Nasal swab for respiratory polymerase chain reaction (PCR) panel was positive for adenovirus.
Five days after admission, his fever remitted for 48 hours, but he developed left hypochondriac pain with a relapse of fever. Serum amylase and lipase levels were within normal limits. Ultrasound of the abdomen showed hypoechoic areas in the peripheral aspects of the spleen and altered echogenicity in the subcapsular region, suggesting SI with adjacent subcapsular hemorrhage. Doppler scan revealed normal color flow in the splenic hilar artery and vein but no color flow in intrasplenic vessels. These ultrasound findings were confirmed with contrast-enhanced CT of the abdomen (Figs 1 and 2). As part of the evaluation for the infarct, antinuclear antibody titers, high-performance liquid chromatography for hemoglobinopathies (sickle cell anemia), and Epstein–Barr virus (EBV) viral capsid antigen (VCA) immunoglobulin M (IgM) tests were negative. The prothrombotic profile showed positivity for anticardiolipin IgM antibodies, likely the cause of the infarct. Echocardiography revealed normal findings. He was initiated on subcutaneous low-molecular-weight heparin injections, and as his pain and fever subsided, he was discharged on oral rivaroxaban. During follow-up, he showed improvement, and repeat ultrasound confirmed resolution of the infarct.
Fig. 1: Computed tomography coronal images showing large hypodense nonenhancing area replacing the splenic parenchyma with relative sparing of inferior pole and hilum
Fig. 2: CT axial image showing large hypodense area suggestive of splenic infarction
DISCUSSION
Human adenovirus spreads through respiratory droplets, conjunctival contact, and the fecal–oral route.4 Apart from the common presentations such as upper and lower respiratory tract infections, conjunctivitis, and gastroenteritis, HAdv can also cause appendicitis, hepatitis, intestinal intussusception, cardiac manifestations such as myocarditis, dilated cardiomyopathy, and pericarditis. It can also lead to genitourinary manifestations such as cystitis, nephritis, and neurological conditions such as meningoencephalitis.3 Adenoviral infection causing an arterial ischemic stroke (AIS) was reported by Kutlesa et al. in a 4-year-old male child5 and similarly adenovirus causing disseminated intravascular coagulation (DIC) in an immunocompetent child was reported by Hussain et al.6
Splenic infarction occurs as a result of arterial or venous occlusion, often secondary to hematological disorders, cardioembolic events, trauma, liver cirrhosis, pancreatitis, and infections. Clinical features range from asymptomatic cases to severe complications such as bleeding, rupture, pseudocyst formation, and death. SI can be caused by systemic infections such as infective endocarditis (IE), bacteremia without IE, various other pathogens, as well as localized infections of the respiratory tract, skin and soft tissues, hepatobiliary system, intraabdominal organs, and urinary tract.7 Viral etiologies of SI include parvovirus B19, coronaviruses, cytomegalovirus, and EBV. The possible pathophysiology of SI following viral infections involves altered immune response, inflammation of vessel walls, and transient activation of coagulation cascade.
CONCLUSION
Human adenovirus, like other viruses, can cause hematologic manifestations such as SI, AIS, and DIC. To the best of our knowledge, this is the first case report of adenoviral infection associated with SI. We recommend considering adenovirus infection in cases of fever with SI in otherwise previously healthy children.
ORCID
Gajam Siddhartha https://orcid.org/0000-0003-2021-5087
REFERENCES
1. Tebruegge M, Curtis N. Adenovirus infection in the immunocompromised host. Adv Exp Med Biol 2010;659:153–174. DOI: 10.1007/978-1-4419-0981-7_13
2. Shieh WJ. Human adenovirus infections in pediatric population—an update on clinico-pathologic correlation. Biomed J 2022;45(1):38–49. DOI: 10.1016/j.bj.2021.08.009
3. Goeijenbier M, van Wissen M, van de Weg C, et al. Review: viral infections and mechanisms of thrombosis and bleeding. J Med Virol 2012;84(10):1680–1696. DOI: 10.1002/jmv.23354
4. Hong JY, Lee HJ, Piedra PA, et al. Lower respiratory tract infections due to adenovirus in hospitalized Korean children: epidemiology, clinical features, and prognosis. Clin Infect Dis 2001;32:1423–1429. DOI: 10.1086/320146
5. Kutlesa M, Tesović G, Knezović I, et al. Ischemic stroke associated with adenoviral infection in a 4-year-old boy. Wien Klin Wochenschr 2009;121(23-24):776–779. DOI: 10.1007/s00508-009-1286-4
6. Hussain SA, Zafar A, Faisal H, et al. Adenovirus-associated disseminated intravascular coagulation. Cureus 2021;13(3):e14194. DOI: 10.7759/cureus.14194
7. Im JH, Chung MH, Lee HJ. et al. Splenic infarction and infectious diseases in Korea. BMC Infect Dis 2020;20(1):915. DOI: 10.1186/s12879-020-05645-9
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