Fatal adenoviral pneumonitis presenting as an opportunistic infection in a patient with AIDS.

Adenovirus typically presents as a disease of the upper respiratory tract. In contrast to other immunosuppressed hosts, adenoviral pneumonitis has rarely been described in patients with AIDS. Limited case reports implicate adenovirus as a co-pathogen together with PCP or CMV. We describe a patient with AIDS who developed pneumonitis and respiratory failure with adenovirus as the only identified respiratory pathogen. A 47-year-old male with AIDS presented with a history of dry cough, fever, chills, and shortness of breath for 1 week. The patient had discontinued antiretroviral therapy and PCP prophylaxis 12 months prior. His CD4 count was 106 with a viral load of 34,000. Physical exam was significant for thrush and crackles at the right lung base. CXR showed a right lower lobe infiltrate. The patient was initially begun on therapy for community-acquired pneumonia with ceftriaxone and azithromycin. BAL was obtained prior to the start of PCP therapy with TMP/SMX and prednisone. Silver stain and DFA were negative, as were tests for other respiratory pathogens. Levofloxaxin and piperacillin/tazobactam were added to the regimen and the patient was ultimately intubated for respiratory failure. CXR revealed diffuse infiltrates bilaterally. Repeat BAL was again negative for PCP. Fungal stains and cultures, AFB, CMV, Influenza A and B, RSV, and Legionella DFA were also negative. A rickettsial panel and histoplasmosis and coccidioidomycosis serologies were negative. Amphotericin B, doxycycline, and gentamicin were added empirically due to lack of clinical improvement. The patient's clinical condition deteriorated and he expired 5 days later. Subsequently, viral cultures from both BAL collections were positive only for adenovirus. Adenoviral pneumonitis is likely an under recognized cause of opportunistic infection in patients with AIDS and is worthy of further study.

Jason F. Okulicz, MD, and Caroline DeWitt, MD. Wilford Hall Medical Center, Lackland AFB, San Antonio, TX.