Adenoviruses (AdV) are emerging pathogens with a prevalence of 11% viruria and 6.5% viremia in kidney transplant recipients. Although AdV infection is common, interstitial nephritis (ADVIN) is rare with only 13 biopsy proven cases reported in the literature. We report a case of severe ADVIN with characteristic histological features that includes severe necrotizing granulomatous lesion with widespread tubular basement membrane rupture and hyperchromatic smudgy intranuclear inclusions in the tubular epithelial cells. The patient was asymptomatic at presentation, and the high AdV viral load (quantitative PCR>2,000,000 copies/mL in the urine and 646,642 copies/mL in the serum) confirmed the diagnosis. The patient showed excellent response to a combination of immunosuppression reduction, intravenous cidofovir, and immunoglobulin therapy resulting in complete resolution of infection and recovery of allograft function. Awareness of characteristic biopsy findings may help to clinch the diagnosis early which is essential since the disseminated infection is associated with high mortality of 18% in kidney transplant recipients. Cidofovir is considered the agent of choice for AdV infection in immunocompromised despite lack of randomized trials, and the addition of intravenous immunoglobulin may aid in resolution of infection while help prevention of rejection. 1. Introduction Adenoviruses (AdV) are emerging pathogens in solid organ transplant recipients with clinical manifestation that ranges from subclinical infection to fatal outcome. The reported prevalence of AdV infection during the first year after kidney transplant (KT) is 11% by urine culture and 6.5% by serum PCR [1, 2]. Manifestations of urinary tract involvement may include hemorrhagic cystitis, ureteral obstruction with hydronephrosis, acute tubular necrosis, interstitial nephritis, or a mass lesion in the kidney [3–5]. Adenovirus interstitial nephritis (ADVIN) is rare in kidney transplant recipients with 13 biopsy proven cases reported in the literature [6–8]. We report a case of severe necrotizing ADVIN with characteristic morphology on biopsy within three weeks after kidney transplantation. 2. Case Report 2.1. Clinical History and Laboratory Data A 44-year-old African American male with end-stage renal disease from hypertensive nephrosclerosis received a four-antigen mismatch, flow crossmatch negative deceased donor kidney transplantation. The patient received IL-2 receptor antagonist (Basiliximab) for induction and tacrolimus, mycophenolate mofetil (MMF), and prednisone for maintenance
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