Adenovirus hemorrhagic cystitis

Dr. Coetzer presented a fascinating case of an immunocompromised man with history of renal transplantation who presented with fever, acute onset hematuria and flank pain.

We walked through an anatomical diagnostic schema for hematuria before we dived into our HPI questions

Picture courtesy of  UpToDate

Picture courtesy of UpToDate

His UA had >1000 RBC, 9 WBC, no protein, no casts, no dysmorphic RBC’s. The patient had a CT without contrast that was not suggestive of nephrolithiasis or masses and the allograft appeared normal. There were no significant occupational exposures or culprit medications.

Given his immunocompromised state, infectious workup included EBV, CMV, quantiferon TB , Brucella antibodies, coccioides antibodies, urine Histoplasma antibodies, ureoplasma, mycoplasma, blood and urine cultures, all of which were negative. Adenovirus viral load was found to be >590,000,000 by PCR, consistent with adenovirus hemorrhagic cystitis (AHC).


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References:

—deVries CR, Freiha FS. Hemorrhagic cystitis: a review. J Urol. 1990 Jan. 143(1):1-9.

—Dorairajan, L., Manikandan, R., & Kumar, S. (2010). Hemorrhagic cystitis: A challenge to the urologist. Indian Journal of Urology, 26(2), 159. doi: 10.4103/0970-1591.65380

—Hofland, C., Eron, L., & Washecka, R. (2004). Hemorrhagic adenovirus cystitis after renal transplantation. Transplantation Proceedings, 36(10), 3025–3027. doi: 10.1016/j.transproceed.2004.10.090

—Bradshaw, C. S. (2002). Characteristics of adenovirus associated urethritis. Sexually Transmitted Infections, 78(6), 445–447. doi: 10.1136/sti.78.6.445

—Akiyama, H., Kurosu, T., Sakashita, C., Inoue, T., Mori, S.-I., Ohashi, K., … Kitamura, T. (2001). Adenovirus Is a Key Pathogen in Hemorrhagic Cystitis Associated with Bone Marrow Transplantation. Clinical Infectious Diseases, 32(9), 1325–1330. doi: 10.1086/319992

—Parasuraman, R., Zhang, P. L., Samarapungavan, D., Rocher, L., & Koffron, A. (2013). Severe Necrotizing Adenovirus Tubulointerstitial Nephritis in a Kidney Transplant Recipient. Case Reports in Transplantation, 2013, 1–5. doi: 10.1155/2013/969186