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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 11  |  Issue : 3  |  Page : 215-217

Adenovirus causing acute encephalitis in an immunocompetent elderly female - The first case reported in literature


1 Department of Internal Medicine, Military Hospital, Ambala, Haryana, India
2 Department of Anesthesiology and Critical Care, Military Hospital, Ambala, Haryana, India

Date of Submission17-Oct-2022
Date of Acceptance06-Nov-2022
Date of Web Publication30-Nov-2022

Correspondence Address:
Vishal Mangal
Department of Internal Medicine, Military Hospital, Ambala - 133 001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjhs.sjhs_124_22

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  Abstract 


Encephalitis is a leading cause of morbidity and mortality in elderly patients. Prognostic factors independently associated with an adverse clinical outcome are age ≥65, fever, Glasgow Coma Scale score <13, and seizures. The most common viruses causing encephalitis are herpes simplex virus, varicella-zoster, human immunodeficiency virus, Epstein–Bar virus, cytomegalovirus, Japanese encephalitis, and arboviruses. We hereby present a case of a 55-year-old female who presented with a new-onset seizure, fever, and altered behavior. She was clinically diagnosed with encephalitis. Her diagnostic lumbar puncture was suggestive of lymphocytic pleocytosis, red blood cells, and raised protein with normal glucose. She had normal magnetic resonance imaging of the brain; however, cerebrospinal fluid demonstrated the presence of adenovirus DNA by real-time polymerase chain reaction. She was managed conservatively; however, the course was complicated by drug-induced acute kidney injury. Our patient had a favorable outcome. To the best of our knowledge, this is the first case of adenovirus encephalitis in an elderly immunocompetent female. Adenovirus is a rare cause of encephalitis in adults; however, high index of suspicion and timely management with available antivirals can lead to successful outcomes.

Keywords: Adenovirus, elderly, encephalitis, immunocompetent


How to cite this article:
Mangal V, Yadav S, Kaur KB. Adenovirus causing acute encephalitis in an immunocompetent elderly female - The first case reported in literature. Saudi J Health Sci 2022;11:215-7

How to cite this URL:
Mangal V, Yadav S, Kaur KB. Adenovirus causing acute encephalitis in an immunocompetent elderly female - The first case reported in literature. Saudi J Health Sci [serial online] 2022 [cited 2023 Feb 7];11:215-7. Available from: https://www.saudijhealthsci.org/text.asp?2022/11/3/215/362376




  Introduction Top


Encephalitis is a leading cause of morbidity and mortality in elderly patients. International encephalitis consortium defines encephalitis as the presence of altered mental status without alternative cause and any two of the following minor criterion: (a) Presence of fever 72 h after or before presentation, (b) New-onset focal neurological deficit, (c) New-onset seizures, (d) Cerebrospinal fluid (CSF) white cell count >5/μL, (e) New lesions on neuroimaging, and (f) Abnormal electroencephalography.[1] Prognostic factors independently associated with an adverse clinical outcome are age ≥65, fever, Glasgow Coma Scale score <13, and seizures.[2] The most common viruses causing encephalitis are herpes simplex virus, varicella-zoster, human immunodeficiency virus, Epstein–Bar Virus, cytomegalovirus, Japanese encephalitis, and arboviruses.[3] We hereby present the case of a 55-year-old female who presented with a new-onset seizure, fever, and altered behavior and had positive adenovirus real-time polymerase chain reaction (PCR) in CSF. She was managed conservatively with a favorable outcome. To the best of our knowledge, this is the first case of adenovirus encephalitis in an immunocompetent adult reported in literature.


  Case Report Top


A 56-year-old female with a history of hypertension and diabetes mellitus presented with an episode of generalized tonic–clonic seizure while sitting on a bed, followed by a fall on the ground. She sustained an injury to the right side of her forehead. It was associated with frothing from the mouth and uprolling of eyeballs; however, there was no history of tongue bite or bladder bowel incontinence. At the time of admission, she was conscious, with a pulse rate of 86 beats per minute, and her blood pressure was 142/72 mm of Hg. She had a black eye on the right side [Figure 1]. Systemic examination was essentially normal. An urgent non-contrast computerized tomography of head was done, which was normal, and the patient was admitted to the female ward. The same day in the evening, at around 1800 h, she again had an episode of generalized tonic–clonic seizure associated with urinary incontinence and postictal confusion lasting 15–20 min. She was administered a loading dose of injection dilantin sodium 20 mg/kg over 1 h. Initial laboratory parameters were essentially normal [Table 1]. On the 2nd day of admission, in the morning patient developed agitated behavior, increased spontaneous speech, she was disoriented to time. She had choreiform movements of the left upper limb but did not have any focal neurological deficit. She had also developed fever. Due to new-onset seizure, fever, and altered behavior, the clinical diagnosis of infective encephalitis was considered with suspicion of herpes simplex encephalitis. She underwent urgent contrast-enhanced magnetic resonance imaging of the brain, which did not show any features of encephalitis however incidentally revealed a 3.1 mm nodule in the right middle frontal gyrus. It was isointense on T1 and hypointense on T2 and fluid-attenuated inversion recovery sequences and showed blooming on gradient echo sequences. No perilesional edema was present. She underwent a diagnostic lumbar puncture which showed lymphocytic pleocytosis with red blood cells (RBCs), raised proteins, and normal glucose levels [Table 2]. She was administered injection acyclovir 750 mg intravenous (iv) eight hourly and injection ceftriaxone 2 g iv 12 hourly. She was also started on dexmedetomidine infusion at the rate of 0.3 μg/kg/h. CSF was sent for a real-time PCR panel for the common viruses such as herpes simplex 1 and 2, echovirus, adenovirus, Epstein–Barr virus, human herpes virus 7, human herpes virus 6, human parechovirus, and cytomegalovirus. On day three of admission, she was started on tube feeds. She was noted to have persistent tachycardia. The electrocardiogram showed sinus tachycardia with nonspecific ST and T changes. A clinical diagnosis of viral myocarditis was considered. On day 5 of admission, dexmedetomidine infusion was tapered, and the patient was started on an oral semisolid diet. She developed azotemia and raised serum potassium with numerous RBCs on urine routine and microscopic examination. She had subnephrotic range proteinuria [Table 2]. A clinical diagnosis of acyclovir-induced acute kidney injury was considered; meanwhile, CSF tested positive for adenovirus and negative for HSV1 and 2. Acyclovir was stopped, and the patient was managed conservatively with hydration and loop diuretics to maintain a urine output of 150 ml/h. Subsequently patient improved, and by day nine, renal function had returned to baseline. She was discharged walking with no neurological deficit.
Figure 1: The red arrow shows the right black eye

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Table 1: Routine laboratory parameters

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Table 2: Special laboratory investigations

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  Discussion Top


Human adenoviruses are a group of double-stranded DNA viruses consisting of more than 60 serotypes and divided into seven subgroups. They generally cause febrile illnesses in young children such as pharyngitis, coryza associated with conjunctivitis, bronchitis, and laryngotracheitis.[4] Rarely can they cause gastrointestinal, ophthalmologic, genitourinary, and neurologic diseases. Most of the adults have serologic evidence of prior adenoviral infection by the age of 10 years.

From 2006 to 2010, three extensive prospective studies on encephalitis, which mainly included adults involving 789 patients, were conducted, and no case of adult encephalitis was attributed to adenovirus.[5],[6],[7] However, in children, adenovirus is responsible for 3.3%–5% of the central nervous system (CNS) disease cases, including febrile seizures, encephalitis, afebrile seizure, and meningitis.[8] The median age is 2 years in children with adenovirus-related CNS disease. Our patient was a 55-year-old female who presented with an afebrile seizure followed by fever and encephalitis. This presentation is different as compared to children.

In children, the most common prodrome is an upper respiratory illness, vomiting, and diarrhea. Subsequently, in hospital few children developed pneumonia, hepatitis, and coagulopathy; however, our patient did not have any prodrome. She presented with the first episode of afebrile seizure and subsequently developed fever and altered behavior.[8] Serotype 7, followed by serotypes 3 and 2, are the most common serotypes associated with adenovirus CNS disease. In our case, we did not perform the serotyping of the detected adenovirus.

The most common antivirals against adenovirus are cidofovir, ribavirin, ganciclovir, and brincidofovir. Current recommendations for treating adenovirus are limited to immunocompromised patients such as allogeneic stem-cell transplant recipients who carry the highest risk of adenovirus-related life-threatening complications.[9] The treatment approaches could be prophylactic, preemptive (based on the detection of the virus before the onset of symptoms), and therapeutic; however, the European Conference on Infections in leukemia does not recommend prophylactic antiviral therapy.[10] We did not use any of the above antivirals in our patient; however, these drugs can be used in cases that do not show adequate improvement.


  Conclusion Top


Adenovirus typically causes upper respiratory illnesses in children, with only 5% of children developing CNS disease. However, adenovirus can very rarely cause acute encephalitis in immunocompetent adults. The high index of suspicion and the timely use of available antivirals can lead to favorable outcomes even in adults.

Patient consent

The authors certify that patient consent was taken in writing for publication of this case report.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Ethical clearance

Our institute does not require ethical clearance for individual case reports.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Venkatesan A, Tunkel AR, Bloch KC, Lauring AS, Sejvar J, Bitnun A, et al. Case definitions, diagnostic algorithms, and priorities in encephalitis: Consensus statement of the international encephalitis consortium. Clin Infect Dis 2013;57:1114-28.  Back to cited text no. 1
    
2.
Hansen MA, Samannodi MS, Castelblanco RL, Hasbun R. Clinical epidemiology, risk factors, and outcomes of encephalitis in older adults. Clin Infect Dis 2020;70:2377-85.  Back to cited text no. 2
    
3.
Stahl JP, Mailles A, Dacheux L, Morand P. Epidemiology of viral encephalitis in 2011. Med Mal Infect 2011;41:453-64.  Back to cited text no. 3
    
4.
Edwards KM, Thompson J, Paolini J, Wright PF. Adenovirus infections in young children. Pediatrics 1985;76:420-4.  Back to cited text no. 4
    
5.
Granerod J, Cunningham R, Zuckerman M, Mutton K, Davies NW, Walsh AL, et al. Causality in acute encephalitis: Defining aetiologies. Epidemiol Infect 2010;138:783-800.  Back to cited text no. 5
    
6.
Mailles A, Stahl JP, Steering Committee and Investigators Group. Infectious encephalitis in france in 2007: A national prospective study. Clin Infect Dis 2009;49:1838-47.  Back to cited text no. 6
    
7.
Glaser CA, Honarmand S, Anderson LJ, Schnurr DP, Forghani B, Cossen CK, et al. Beyond viruses: Clinical profiles and etiologies associated with encephalitis. Clin Infect Dis 2006;43:1565-77.  Back to cited text no. 7
    
8.
Schwartz KL, Richardson SE, MacGregor D, Mahant S, Raghuram K, Bitnun A. Adenovirus-associated central nervous system disease in children. J Pediatr 2019;205:130-7.  Back to cited text no. 8
    
9.
Lion T. Adenovirus infections in immunocompetent and immunocompromised patients. Clin Microbiol Rev 2014;27:441-62.  Back to cited text no. 9
    
10.
Matthes-Martin S, Feuchtinger T, Shaw PJ, Engelhard D, Hirsch HH, Cordonnier C, et al. European guidelines for diagnosis and treatment of adenovirus infection in leukemia and stem cell transplantation: Summary of ECIL-4 (2011). Transpl Infect Dis 2012;14:555-63.  Back to cited text no. 10
    


    Figures

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    Tables

  [Table 1], [Table 2]



 

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