Lilley Cullen M, Borys Ewa, Picken Maria M
Department of Pathology, Loyola University Chicago Stritch School of Medicine, Maywood, USA.
Department of Pathology, Loyola University Medical Center, Maywood, USA.
Cureus. 2023 May 2;15(5):e38452. doi: 10.7759/cureus.38452. eCollection 2023 May.
Adenoviral infections in post-transplant patients have been described in multiple organ systems, most classically the lung, liver, and alimentary tract. In the genitourinary tract, hemorrhagic cystitis is most frequently observed. Clinically apparent renal involvement with adenovirus is rare, and adenovirus-associated interstitial nephritis (AAIN) is an uncommon cause of renal allograft failure. Here, we present three cases of AAIN in patients who, after prompt diagnosis and treatment adjustment, experienced a return of allograft function. All patients were on standard triple therapy with tacrolimus levels within the target range at the time of biopsy. None of the patients had respiratory symptoms, and despite diarrhea, colon biopsies were negative. Only case one had positive adenovirus serology (IgG only) and case three had positive urine; two patients had leukopenia without neutropenia. Renal biopsies showed a characteristic granulomatous tubulocentric mixed lymphocytic and neutrophilic infiltrate. Adenovirus immunohistochemistry (IHC) showed strong staining in the tubular epithelium (nuclear and cytoplasmic) while staining for polyomavirus was negative. A follow-up biopsy two months after the diagnosis of AAIN in one patient revealed persistent cytopathic effects with negative adenoviral IHC staining while a biopsy at one year in another patient showed glomerular and tubulointerstitial scarring. AAIN is an uncommon but important etiology to consider in cases of acute renal allograft dysfunction. Although the presenting symptoms for AAIN are nonspecific, hematuria is frequently noted. Adenovirus IHC should be considered in cases with granulomatous inflammation associated with necrosis and mixed inflammatory infiltrate. As demonstrated in this single-institution case series, prompt diagnosis can result in the preservation of the renal allograft. Lasting cytopathic effects after adenoviral infection should also be considered in patients with a history, or potential history, of AAIN.
移植后患者的腺病毒感染已在多个器官系统中被描述，最典型的是肺、肝和消化道。在泌尿生殖道中，出血性膀胱炎最为常见。临床上明显的腺病毒累及肾脏情况罕见，腺病毒相关间质性肾炎（AAIN）是肾移植失败的罕见原因。在此，我们报告三例AAIN患者，经及时诊断和调整治疗后，移植肾功能恢复。所有患者均接受标准三联疗法，活检时他克莫司水平在目标范围内。所有患者均无呼吸道症状，尽管有腹泻，但结肠活检为阴性。仅病例一腺病毒血清学阳性（仅IgG），病例三尿液阳性；两名患者有白细胞减少但无中性粒细胞减少。肾活检显示特征性的以肉芽肿为中心的混合淋巴细胞和中性粒细胞浸润。腺病毒免疫组化（IHC）显示肾小管上皮（核和胞质）有强染色，而多瘤病毒染色为阴性。一名患者诊断AAIN两个月后的随访活检显示持续的细胞病变效应，腺病毒IHC染色阴性，而另一名患者一年后的活检显示肾小球和肾小管间质瘢痕形成。AAIN是急性肾移植功能障碍病例中一种罕见但重要的病因。尽管AAIN的表现症状不具特异性，但血尿经常被注意到。对于伴有坏死和混合性炎症浸润的肉芽肿性炎症病例，应考虑腺病毒IHC检查。正如这个单机构病例系列所示，及时诊断可使肾移植得以保留。对于有AAIN病史或潜在病史的患者，也应考虑腺病毒感染后的持久细胞病变效应。
