A 30-year-old woman with a history of a renal transplant for lupus nephritis presented with ten days of painful urination, pain over her transplanted kidney, and “hawaiian punch” urine. She also complained of chills and headache and became febrile on the day of presentation. The patient reported compliance with her immunosuppressive regimen, prednisone, tacrolimus, and mycophenylate mofetil.
Initial temperature was 39.4°C, pulse was 116, and blood pressure was 92/64. She appeared uncomfortable with suprapubic tenderness and pain over her transplanted kidney in the right lower quadrant. She had no costovertebral angle tenderness. Urinalysis showed >182 white cells. Creatinine was 1.6 (baseline 0.8-1.0). Ultrasound of the transplanted kidney revealed pyelitis and possibly pyelonephritis with normal resistive indices.
The patient was started on vancomycin and cefepime, but she remained febrile over the next 48 hours. Non-contrasted CT scan of the abdomen and pelvis confirmed pyelonephritis without nephrolithiasis or abscess. Blood cultures were negative and urine culture grew mixed urogenital flora. She developed diarrhea, so viral testing was performed on stool, blood, and urine. Adenovirus PCR was positive in all three specimens, confirming a diagnosis of disseminated adenovirus infection. She was treated with cidofovir and probenicid. Both urine and blood PCR remained positive after 8 days, so she was transitioned to oral brincidofovir prior to discharge. Three weeks later, repeat adenovirus testing was negative.
Urinary tract infection (UTI) is a common reason for hospital admission. The most frequent cause is Escherichia coli; however, a broader spectrum of microbes must be considered in immunocompromised patients, including other gram-negative and gram-positive bacteria, viruses, and fungi. Our patient presented with classic symptoms of pyelonephritis, but was found to have disseminated adenovirus.
Adenoviruses are non-enveloped, double-stranded, DNA viruses associated with self-limited respiratory, gastrointestinal, and ocular illness in immunocompetent hosts. In solid organ transplant recipients, however, adenovirus infection most frequently manifests as hemorrhagic cystitis and can rarely target the graft organ itself. Outcomes range from rapid clearing of virus with recovery of graft function to graft failure and death. Disseminated disease, defined as the involvement of two or more organs not including viremia, is associated with high morbidity and mortality. Treatment includes reduction of immunosuppression and off-label use of cidofovir often administered with probenecid to prevent nephrotoxicity. An orally bioavailable, lipid conjungate form called brincidofovir has recently been developed and, in preliminary studies, has not been associated with nephrotoxicity.
The majority of UTIs are readily treatable with empiric antibiotics targeting common uropathogens. However, in the setting of immunosuppression, other etiologies including adenovirus should be considered early in the diagnostic evaluation to minimize morbidity and mortality.
To cite this abstract:Ciccone E, Stephens J. Pyelonephritis in an Immunocompromised Patient: An Uncommon Presentation of the Common Cold. Abstract published at Hospital Medicine 2016, March 6-9, San Diego, Calif. Abstract 472. Journal of Hospital Medicine. 2016; 11 (suppl 1). https://www.shmabstracts.com/abstract/pyelonephritis-in-an-immunocompromised-patient-an-uncommon-presentation-of-the-common-cold/. Accessed May 22, 2019.