Adenovirus Infection Presenting as a Solitary Mass Lesion With Lymphocytic Effusion in a Lung Transplant Recipient

October 2014, Vol 146, No. 4_MeetingAbstracts Transplantation | October 2014

Adenovirus Infection Presenting as a Solitary Mass Lesion With Lymphocytic Effusion in a Lung Transplant Recipient Brian Cohee, MD; Oksana Shlobin, MD; Mani Haresh, MD; Anne Brown, MD; Sandeep Khandhar, MD; Margaret Fregoso, NP; Kara Germano, NP; Steven Nathan, MD; Shahzad Ahmad, MD Inova Fairfax Hospital, Fairfax, VA

Chest. 2014;146(4_MeetingAbstracts):984A. doi:10.1378/chest.1987862

Abstract SESSION TITLE: Transplant Cases SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Sunday, October 26, 2014 at 03:15 PM - 04:15 PM INTRODUCTION: Adenovirus infection in lung transplant recipients is associated with poor outcomes and bronchiolitis obliterans syndrome. While adenovirus pneumonia typically presents as diffuse infiltrates, mass lesions and pleural effusions have been reported in immunosuppressed patients.

CASE PRESENTATION: A 62-year-old male was admitted for fatigue, fevers, abdominal pain and dyspnea six weeks after undergoing a left lung transplant for sarcoidosis. CT scan of the chest showed a large left-sided exudative pleural effusion with lymphocytic predominance and a small left upper lobe nodule surrounded by a halo of ground glass. When cultures from all sources remained negative, he was treated with a 3day course of glucocorticoids for possible acute rejection. Despite tube thoracostomy and antibiotics, the patient continued to have fevers and a repeat CT of the chest showed an interval growth of the left upper lobe nodule. Transbronchial lung biopsy was negative for infection or acute rejection. Broncheoalveolar lavage showed acute inflammation and adenovirus was detected on PCR. Subsequent quantitative PCR of the serum was positive with >2,000,000 copies/mL. A CT guided biopsy of the left upper lobe lesion showed a necrotizing pneumonia and rare cells with smudged chromatin. Immunostain for adenovirus was positive. The patient improved without antiviral therapy. Follow up studies showed a decrease in serum PCR to 6,294 copies 2 weeks later. Follow up CT scan 2 months later showed partial resolution of the mass and complete resolution of L sided pleural effusion. DISCUSSION: Rounded pneumonia is a common presentation in children, but is unusual in adults. Reported viral causes include CMV and Adenovirus, but this presentation has never been described in a lung transplant recipient. Adenovirus pneumonia in lung transplant patients has a poor prognosis but several treatments have been described in small case series. CONCLUSIONS: We report the first case of adenovirus pneumonia presenting as a mass lesion with an associated pleural effusion in a lung transplant recipient. Adenoviral infection should be considered in immunosuppressed patients presenting with a mass lesion. Antiviral therapy may not be required in management. Reference #1: Ison MG and Green M. Adenovirus in solid organ transplant recipients. Am J Transplant 2009;9(4):S161-5. Reference #2: Mochizuki K, Kondo Y, Hosokawa K, et al. Adenovirus pneumonia presenting with nodular shadows on chest X-ray in two unrelated allogeneic bone marrow transplant recipients. Intern Med 2014;53:499-503. DISCLOSURE: The following authors have nothing to disclose: Brian Cohee, Oksana Shlobin, Mani Haresh, Anne Brown, Sandeep Khandhar, Margaret Fregoso, Kara Germano, Steven Nathan, Shahzad Ahmad No Product/Research Disclosure Information