1. Prepared by Gabrielle Bailey MD and reviewed by Heba Mostafa MBBCh, PhD, D(ABMM)
An adult patient presented to the Emergency Department with dizziness and rigors. Their past medical history includes diffuse large B-cell lymphoma (on R-CHOP chemotherapy regimen), ulcerative colitis (on mesalamine and steroids), cirrhosis complicated by ascites and hepatic encephalopathy, and colon cancer status-post ileocolonic resection and end ileostomy. They presented after receiving a dose of chemotherapy followed by filgrastim, and then felt fatigued with decreased appetite. The patient also noted increased urine and stool output from their ostomy site. The patient was concerned for dehydration, which prompted them to go to the ED.
Vitals:
Afebrile, HR 98 bpm, RR 18, BP 125/75 mmHg, SpO2 100% on room air
Relevant Labs:
WBC: 26.42 K/cu mm (trended upwards to 91.01 K/cu mm)
Creatinine: 4.6 mg/dL (up from 1.3 mg/dL baseline)
Lactate: 2.7 mmol/L
Urinalysis showed 12 WBCs/HPF
CTA of the abdomen and pelvis showed no acute findings in the gastrointestinal tract. There was unchanged severe cirrhosis as postsurgical changes of the right partial colectomy with right lower
quadrant end ileostomy.
The infectious disease clinicians were consulted with concern for urosepsis or a gastrointestinal infection from gut translocation. Blood and urine cultures, fungal markers, Clostridium difficile toxin, and stool cultures were obtained.
The patient's work-up revealed:
Blood cultures, urine cultures negative
Stool bacterial NAT negative, C.difficile toxin negative
Stool Norovirus negative
CMV IgM negative
Fecal calprotectin: 419 mcg/g (elevated)
Stool lactoferrin positive
Beta-D glucan and galactomannan negative
Plasma adenovirus quantitative PCR resulted positive (>100K copies)
Adenovirus was also detected in the patient's urine and stool. Unfortunately, the patient had persistent bloody ostomy output and was found to have an actively bleeding duodenal ulcer, which led to hypovolemia, refractory shock, and eventually multiorgan failure. They were transitioned to comfort care and passed away.
Question:
Which of the following is true of enteric adenovirus?
