A 40 year old woman who underwent kidney transplant due to hypertension. Three weeks post transplant, she was admitted to ER for fever and diarrhea. Serum creatinine was 3.1 mg/dL. Her lab showed leukocytosis. Bacterial and fungal cultures were negative. PCR adenovirus testing on stool was negative. Donor specific antibodies were negative.  Plasma BK DNA was negative. 

C4d is negative in the peritubular capillaries. 

Etiology/Pathogenesis

• Nonenveloped, double-stranded DNA virus

Clinical Issues

• Fever

• Hemorrhagic cystitis usual with kidney involvement

  • Gross hematuria

• Acute renal failure

• Tenderness of allograft if involved

• Blood real-time polymerase chain reaction for diagnosis and surveillance

• Cidofovir, ribavirin, intravenous immunoglobulin

• Recovery common if localized

• > 60% fatal if disseminated

Microscopic

• Granulomatous inflammation

• Necrosis of tubules

• Interstitial hemorrhage

• Smudgy, basophilic, intranuclear inclusions in tubular cells

Ancillary Tests

• Positive for AdV by immunohistochemistry

• EM shows characteristic 60- to 80-nm virions

Acute T-Cell-Mediated Rejection

• Reactive atypia of tubular nuclei may mimic viral inclusions

  • No viral antigen present

• Granulomas sometimes seen associated with tubular destruction in acute T-cell-mediated rejection

• Less severe hemorrhage and tubular necrosis than AdV

• AdV lacks endarteritis [and C4d(+)]

Polyomavirus Nephritis

• Positive SV40 immunohistochemistry

• Less hemorrhage and tubular necrosis than AdV

• More plasma cells and less granulomatous inflammation

Tuberculosis

• Acid-fast bacilli, no hemorrhage

Aspergillosis

• Septate hyphae with 45° angle branching

Bacterial Pyelonephritis

• Intratubular and interstitial neutrophils

Drug-Induced Acute Interstitial Nephritis

• Hemorrhage and necrosis minimal

• No viral antigen present

• More prominent eosinophils

1- DOI: https://doi.org/10.1053/j.ajkd.2017.11.001 

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