View Article PDF

A 32-year-old health worker presented to the emergency department with a three-day history of headache, left eye pain, fevers and rigors. There was no eye swelling or change in vision and no associated rash. Her past medical history included only asthma and a previous tonsillectomy.

On examination she was tachycardic (heart rate 116bpm), hypotensive (blood pressure 88/50mmHg) and febrile (40°C). The external upper and lower eyelids appeared erythematous bilaterally. The upper lids were everted and diffuse follicular conjunctivitis was seen in both eyes (Figure 1A). The bulbar conjunctivae were injected bilaterally but not chemotic. The anterior chambers were quiet and both corneas were clear without fluorescein uptake. There was overt painless cervical lymphadenopathy in the anterior and posterior triangles of the neck. She was photophobic without evidence of neck stiffness and the remainder of the neurological examination was normal. Examination of the cardiovascular, respiratory and gastrointestinal systems was otherwise unremarkable.

Figure 1A: Bilateral diffuse follicular conjunctivitis present on admission.

c

Empiric antibiotics for the possibility of meningitis were administered in conjunction with intravenous fluids.

Initial investigations revealed a normal haemoglobin and white cell count with a mild thrombocytopenia (platelets 134x10(9)/L). The urea and electrolytes were normal, however the CRP was elevated (115mg/L). Blood cultures were negative. Her CSF had a white cell count of 2x10(6)/L, normal protein and glucose, negative gram stain and no subsequent growth from bacterial culture. There was serological evidence of prior exposure to EBV but not to CMV or toxoplasma.

CT imaging of the head and neck demonstrated low-grade pan-sinusitis of the paranasal sinuses, marked thickening of the soft palate and uvula, and extensive cervical adenopathy extending from the skull base to the thoracic inlet involving both anterior and posterior chains bilaterally (Figure 2). There was minimal periorbital oedema.

On Day 2 she briefly developed a blanching macular exanthem on her abdomen and thighs (Figure 1B), which spontaneously resolved.

Figure 1B: A blanching macular exanthema developed on day 2.

c

Figure 2: A transverse CT section of the neck demonstrates enlarged lymph nodes (arrows).

c

Respiratory multiplex PCR (Fast Track Diagnostics Respiratory Pathogens 21) of a nasopharyngeal swab was positive for adenovirus. This was also detected on specific adenovirus PCR from a swab of the left eye. Subsequent typing completed by the Institute of Environmental Science and Research (ESR) New Zealand using PCR and sequencing techniques revealed this to be adenovirus type 4.1

Over the next several days she continued to improve clinically and was discharged with GP follow-up to ensure resolution of lymphadenopathy. She was stood down from work until her symptoms had completely resolved.

Discussion

Pharyngoconjunctival fever is a constellation of febrile pharyngitis, benign follicular conjunctivitis and cervical adenitis. Given its highly infectious nature and many well-described outbreaks, the recognition of its clinical features has important public health implications.

Worldwide, adenovirus is becoming increasingly prevalent and is sometimes associated with severe morbidity and mortality, particularly in those aged under 18 years.2 Adenovirus can be responsible for infections arising in the respiratory tract (most commonly), gastrointestinal system, urinary tract and eyes. The clinical features of pharyngeal infection (high fever, exudative tonsillitis, leucocytosis and elevated CRP) may mimic severe bacterial infections such as those caused by Group A Streptococci.3 Occasionally adenovirus can cause pharyngoconjunctival fever, which occurs mainly in children. Pharyngoconjunctival fever can be caused by multiple subtypes of adenovirus, but adenovirus types 3 and 7 are the most common.4 This clinical syndrome is most frequently described in outbreaks within schools, school camps and swimming pools; an outbreak in a swimming pool in Spain in 2008 was attributed to adenovirus type 4.5

Pharyngoconjunctival fever outbreaks are more often reported in Australia, the US and China, particularly in the summer months.6 We are not aware of any literature describing an outbreak of pharyngoconjunctival fever in New Zealand. However, in line with global epidemiological trends adenovirus is also becoming more common in New Zealand with 1,802 cases reported in 2015 compared to only 842 cases in 2014.7 The predominant serotype isolated in 2015 was type 7 (61%), followed by type 3 (10%) and of those whose clinical details are available, the majority presented with respiratory symptoms, with 50 patients admitted to hospital (including nine requiring ICU) and two deaths.7

Adenovirus is highly contagious and can be transmitted via droplet, faecal-oral and contact routes. It is able to survive long periods on environmental surfaces, which increases transmission risk. Medical practices and hospitals, in particular eye outpatient clinics, should be considered as potential sources of transmission. Currently there are no approved antiviral agents for the treatment of adenovirus infections, and in this patient group treatment is supportive. However, in those with severe disease, particularly in the setting of immunocompromise, cidofovir (a nucleoside DNA polymerase inhibitor which has activity against adenovirus) may be tried.8 Of note, this is an unapproved medication available under Section 29 of the Medicines Act 1981.

Due to the morbidity associated with respiratory adenovirus infections in military recruits, successful live oral vaccines for adenovirus types 4 and 7 were developed and began being administered in 1971. The vaccine is currently only available to the US military after large outbreaks caused hospitalisations and fatalities.8,9

Given the potential associated morbidity and mortality, it is important to identify cases of adenoviral infection early and emphasise diligent infection prevention and control practises to reduce the transmission of this virus and the potential for an outbreak.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Kate E Alfeld, Medical Registrar, Department of General Medicine, Christchurch Hospital, Christchurch; Simon C Dalton, Infectious Diseases Physician, Infectious Disease Department, Christchurch Hospital, Christchurch.

Acknowledgements

The photographs and images were used with kind permission of the patient described in this case report.

Correspondence

Dr Kate Alfeld, Christchurch Public Hospital, Private Bag 4710, Christchurch.

Correspondence Email

kalfeld4@hotmail.com

Competing Interests

Nil.

  1. Sarantis H, Johnson G, Brown M, et al. Comprehensive detection and serotyping of human adenovirus by PCR and sequencing. Journal of Clinical Microbiology 2004; 42:3963–3969.
  2. Ghebremedhin B. Human adenovirus: Viral pathogen with increasing importance. European Journal of Microbiology and Immunology. 2014; Mar4(1):26–33.
  3. Dominguez O, Rojo P, de Las Heras S, et al. Clinical presentation and characteristics of pharyngeal adenovirus infections. Pediatr Infect Dis J 2005; 24(8):733–4.
  4. Foy HM, Cooney MK, Hatlen JB. Adenovirus type 3 epidemic associated with intermittent chlorination of a swimming pool. Archives of Environmental Health: An International Journal. 1968; Nov17(5):795–802.
  5. Artieda J, Pineiro L, Gonzalez MC, et al. A swimming pool-related outbreak of pharyngoconjunctival fever in children due to adenovirus type 4, Gipuzkoa, Spain, 2008. Eurosurveillance Feb 2009;14(8).
  6. Zhang L, Zhao N, Sha J, Wang C, et al. Virology and epidemiology analyses of global adenovirus-associated conjunctivitis outbreaks, 1953–2013. Epidemiology & Infection. 2016 Jun; 144(8):1661–72.
  7. Institute of Environmental Science and Research, New Zealand. (2018). Virology Annual Report 2015. [online] Available at: http://surv.esr.cri.nz/PDF_surveillance/Virology/VirAnnRpt/VirAnn2015.pdf [Accessed 1 Feb. 2018]
  8. Bennett JE, Dolin R, Blaser MJ. Mandell, Douglas, and Bennett’s principles and practice of infectious diseases. Philadelphia, PA:Elsevier/Saunders, 2015.
  9. Centers for Disease Control and Prevention. (2018). Adenovirus Vaccine Information Statement. [online] Available at: http://www.cdc.gov/vaccines/hcp/vis/vis-statements/adenovirus.html [Accessed 1 Feb. 2018]


For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

A 32-year-old health worker presented to the emergency department with a three-day history of headache, left eye pain, fevers and rigors. There was no eye swelling or change in vision and no associated rash. Her past medical history included only asthma and a previous tonsillectomy.

On examination she was tachycardic (heart rate 116bpm), hypotensive (blood pressure 88/50mmHg) and febrile (40°C). The external upper and lower eyelids appeared erythematous bilaterally. The upper lids were everted and diffuse follicular conjunctivitis was seen in both eyes (Figure 1A). The bulbar conjunctivae were injected bilaterally but not chemotic. The anterior chambers were quiet and both corneas were clear without fluorescein uptake. There was overt painless cervical lymphadenopathy in the anterior and posterior triangles of the neck. She was photophobic without evidence of neck stiffness and the remainder of the neurological examination was normal. Examination of the cardiovascular, respiratory and gastrointestinal systems was otherwise unremarkable.

Figure 1A: Bilateral diffuse follicular conjunctivitis present on admission.

c

Empiric antibiotics for the possibility of meningitis were administered in conjunction with intravenous fluids.

Initial investigations revealed a normal haemoglobin and white cell count with a mild thrombocytopenia (platelets 134x10(9)/L). The urea and electrolytes were normal, however the CRP was elevated (115mg/L). Blood cultures were negative. Her CSF had a white cell count of 2x10(6)/L, normal protein and glucose, negative gram stain and no subsequent growth from bacterial culture. There was serological evidence of prior exposure to EBV but not to CMV or toxoplasma.

CT imaging of the head and neck demonstrated low-grade pan-sinusitis of the paranasal sinuses, marked thickening of the soft palate and uvula, and extensive cervical adenopathy extending from the skull base to the thoracic inlet involving both anterior and posterior chains bilaterally (Figure 2). There was minimal periorbital oedema.

On Day 2 she briefly developed a blanching macular exanthem on her abdomen and thighs (Figure 1B), which spontaneously resolved.

Figure 1B: A blanching macular exanthema developed on day 2.

c

Figure 2: A transverse CT section of the neck demonstrates enlarged lymph nodes (arrows).

c

Respiratory multiplex PCR (Fast Track Diagnostics Respiratory Pathogens 21) of a nasopharyngeal swab was positive for adenovirus. This was also detected on specific adenovirus PCR from a swab of the left eye. Subsequent typing completed by the Institute of Environmental Science and Research (ESR) New Zealand using PCR and sequencing techniques revealed this to be adenovirus type 4.1

Over the next several days she continued to improve clinically and was discharged with GP follow-up to ensure resolution of lymphadenopathy. She was stood down from work until her symptoms had completely resolved.

Discussion

Pharyngoconjunctival fever is a constellation of febrile pharyngitis, benign follicular conjunctivitis and cervical adenitis. Given its highly infectious nature and many well-described outbreaks, the recognition of its clinical features has important public health implications.

Worldwide, adenovirus is becoming increasingly prevalent and is sometimes associated with severe morbidity and mortality, particularly in those aged under 18 years.2 Adenovirus can be responsible for infections arising in the respiratory tract (most commonly), gastrointestinal system, urinary tract and eyes. The clinical features of pharyngeal infection (high fever, exudative tonsillitis, leucocytosis and elevated CRP) may mimic severe bacterial infections such as those caused by Group A Streptococci.3 Occasionally adenovirus can cause pharyngoconjunctival fever, which occurs mainly in children. Pharyngoconjunctival fever can be caused by multiple subtypes of adenovirus, but adenovirus types 3 and 7 are the most common.4 This clinical syndrome is most frequently described in outbreaks within schools, school camps and swimming pools; an outbreak in a swimming pool in Spain in 2008 was attributed to adenovirus type 4.5

Pharyngoconjunctival fever outbreaks are more often reported in Australia, the US and China, particularly in the summer months.6 We are not aware of any literature describing an outbreak of pharyngoconjunctival fever in New Zealand. However, in line with global epidemiological trends adenovirus is also becoming more common in New Zealand with 1,802 cases reported in 2015 compared to only 842 cases in 2014.7 The predominant serotype isolated in 2015 was type 7 (61%), followed by type 3 (10%) and of those whose clinical details are available, the majority presented with respiratory symptoms, with 50 patients admitted to hospital (including nine requiring ICU) and two deaths.7

Adenovirus is highly contagious and can be transmitted via droplet, faecal-oral and contact routes. It is able to survive long periods on environmental surfaces, which increases transmission risk. Medical practices and hospitals, in particular eye outpatient clinics, should be considered as potential sources of transmission. Currently there are no approved antiviral agents for the treatment of adenovirus infections, and in this patient group treatment is supportive. However, in those with severe disease, particularly in the setting of immunocompromise, cidofovir (a nucleoside DNA polymerase inhibitor which has activity against adenovirus) may be tried.8 Of note, this is an unapproved medication available under Section 29 of the Medicines Act 1981.

Due to the morbidity associated with respiratory adenovirus infections in military recruits, successful live oral vaccines for adenovirus types 4 and 7 were developed and began being administered in 1971. The vaccine is currently only available to the US military after large outbreaks caused hospitalisations and fatalities.8,9

Given the potential associated morbidity and mortality, it is important to identify cases of adenoviral infection early and emphasise diligent infection prevention and control practises to reduce the transmission of this virus and the potential for an outbreak.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Kate E Alfeld, Medical Registrar, Department of General Medicine, Christchurch Hospital, Christchurch; Simon C Dalton, Infectious Diseases Physician, Infectious Disease Department, Christchurch Hospital, Christchurch.

Acknowledgements

The photographs and images were used with kind permission of the patient described in this case report.

Correspondence

Dr Kate Alfeld, Christchurch Public Hospital, Private Bag 4710, Christchurch.

Correspondence Email

kalfeld4@hotmail.com

Competing Interests

Nil.

  1. Sarantis H, Johnson G, Brown M, et al. Comprehensive detection and serotyping of human adenovirus by PCR and sequencing. Journal of Clinical Microbiology 2004; 42:3963–3969.
  2. Ghebremedhin B. Human adenovirus: Viral pathogen with increasing importance. European Journal of Microbiology and Immunology. 2014; Mar4(1):26–33.
  3. Dominguez O, Rojo P, de Las Heras S, et al. Clinical presentation and characteristics of pharyngeal adenovirus infections. Pediatr Infect Dis J 2005; 24(8):733–4.
  4. Foy HM, Cooney MK, Hatlen JB. Adenovirus type 3 epidemic associated with intermittent chlorination of a swimming pool. Archives of Environmental Health: An International Journal. 1968; Nov17(5):795–802.
  5. Artieda J, Pineiro L, Gonzalez MC, et al. A swimming pool-related outbreak of pharyngoconjunctival fever in children due to adenovirus type 4, Gipuzkoa, Spain, 2008. Eurosurveillance Feb 2009;14(8).
  6. Zhang L, Zhao N, Sha J, Wang C, et al. Virology and epidemiology analyses of global adenovirus-associated conjunctivitis outbreaks, 1953–2013. Epidemiology & Infection. 2016 Jun; 144(8):1661–72.
  7. Institute of Environmental Science and Research, New Zealand. (2018). Virology Annual Report 2015. [online] Available at: http://surv.esr.cri.nz/PDF_surveillance/Virology/VirAnnRpt/VirAnn2015.pdf [Accessed 1 Feb. 2018]
  8. Bennett JE, Dolin R, Blaser MJ. Mandell, Douglas, and Bennett’s principles and practice of infectious diseases. Philadelphia, PA:Elsevier/Saunders, 2015.
  9. Centers for Disease Control and Prevention. (2018). Adenovirus Vaccine Information Statement. [online] Available at: http://www.cdc.gov/vaccines/hcp/vis/vis-statements/adenovirus.html [Accessed 1 Feb. 2018]


For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

A 32-year-old health worker presented to the emergency department with a three-day history of headache, left eye pain, fevers and rigors. There was no eye swelling or change in vision and no associated rash. Her past medical history included only asthma and a previous tonsillectomy.

On examination she was tachycardic (heart rate 116bpm), hypotensive (blood pressure 88/50mmHg) and febrile (40°C). The external upper and lower eyelids appeared erythematous bilaterally. The upper lids were everted and diffuse follicular conjunctivitis was seen in both eyes (Figure 1A). The bulbar conjunctivae were injected bilaterally but not chemotic. The anterior chambers were quiet and both corneas were clear without fluorescein uptake. There was overt painless cervical lymphadenopathy in the anterior and posterior triangles of the neck. She was photophobic without evidence of neck stiffness and the remainder of the neurological examination was normal. Examination of the cardiovascular, respiratory and gastrointestinal systems was otherwise unremarkable.

Figure 1A: Bilateral diffuse follicular conjunctivitis present on admission.

c

Empiric antibiotics for the possibility of meningitis were administered in conjunction with intravenous fluids.

Initial investigations revealed a normal haemoglobin and white cell count with a mild thrombocytopenia (platelets 134x10(9)/L). The urea and electrolytes were normal, however the CRP was elevated (115mg/L). Blood cultures were negative. Her CSF had a white cell count of 2x10(6)/L, normal protein and glucose, negative gram stain and no subsequent growth from bacterial culture. There was serological evidence of prior exposure to EBV but not to CMV or toxoplasma.

CT imaging of the head and neck demonstrated low-grade pan-sinusitis of the paranasal sinuses, marked thickening of the soft palate and uvula, and extensive cervical adenopathy extending from the skull base to the thoracic inlet involving both anterior and posterior chains bilaterally (Figure 2). There was minimal periorbital oedema.

On Day 2 she briefly developed a blanching macular exanthem on her abdomen and thighs (Figure 1B), which spontaneously resolved.

Figure 1B: A blanching macular exanthema developed on day 2.

c

Figure 2: A transverse CT section of the neck demonstrates enlarged lymph nodes (arrows).

c

Respiratory multiplex PCR (Fast Track Diagnostics Respiratory Pathogens 21) of a nasopharyngeal swab was positive for adenovirus. This was also detected on specific adenovirus PCR from a swab of the left eye. Subsequent typing completed by the Institute of Environmental Science and Research (ESR) New Zealand using PCR and sequencing techniques revealed this to be adenovirus type 4.1

Over the next several days she continued to improve clinically and was discharged with GP follow-up to ensure resolution of lymphadenopathy. She was stood down from work until her symptoms had completely resolved.

Discussion

Pharyngoconjunctival fever is a constellation of febrile pharyngitis, benign follicular conjunctivitis and cervical adenitis. Given its highly infectious nature and many well-described outbreaks, the recognition of its clinical features has important public health implications.

Worldwide, adenovirus is becoming increasingly prevalent and is sometimes associated with severe morbidity and mortality, particularly in those aged under 18 years.2 Adenovirus can be responsible for infections arising in the respiratory tract (most commonly), gastrointestinal system, urinary tract and eyes. The clinical features of pharyngeal infection (high fever, exudative tonsillitis, leucocytosis and elevated CRP) may mimic severe bacterial infections such as those caused by Group A Streptococci.3 Occasionally adenovirus can cause pharyngoconjunctival fever, which occurs mainly in children. Pharyngoconjunctival fever can be caused by multiple subtypes of adenovirus, but adenovirus types 3 and 7 are the most common.4 This clinical syndrome is most frequently described in outbreaks within schools, school camps and swimming pools; an outbreak in a swimming pool in Spain in 2008 was attributed to adenovirus type 4.5

Pharyngoconjunctival fever outbreaks are more often reported in Australia, the US and China, particularly in the summer months.6 We are not aware of any literature describing an outbreak of pharyngoconjunctival fever in New Zealand. However, in line with global epidemiological trends adenovirus is also becoming more common in New Zealand with 1,802 cases reported in 2015 compared to only 842 cases in 2014.7 The predominant serotype isolated in 2015 was type 7 (61%), followed by type 3 (10%) and of those whose clinical details are available, the majority presented with respiratory symptoms, with 50 patients admitted to hospital (including nine requiring ICU) and two deaths.7

Adenovirus is highly contagious and can be transmitted via droplet, faecal-oral and contact routes. It is able to survive long periods on environmental surfaces, which increases transmission risk. Medical practices and hospitals, in particular eye outpatient clinics, should be considered as potential sources of transmission. Currently there are no approved antiviral agents for the treatment of adenovirus infections, and in this patient group treatment is supportive. However, in those with severe disease, particularly in the setting of immunocompromise, cidofovir (a nucleoside DNA polymerase inhibitor which has activity against adenovirus) may be tried.8 Of note, this is an unapproved medication available under Section 29 of the Medicines Act 1981.

Due to the morbidity associated with respiratory adenovirus infections in military recruits, successful live oral vaccines for adenovirus types 4 and 7 were developed and began being administered in 1971. The vaccine is currently only available to the US military after large outbreaks caused hospitalisations and fatalities.8,9

Given the potential associated morbidity and mortality, it is important to identify cases of adenoviral infection early and emphasise diligent infection prevention and control practises to reduce the transmission of this virus and the potential for an outbreak.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Kate E Alfeld, Medical Registrar, Department of General Medicine, Christchurch Hospital, Christchurch; Simon C Dalton, Infectious Diseases Physician, Infectious Disease Department, Christchurch Hospital, Christchurch.

Acknowledgements

The photographs and images were used with kind permission of the patient described in this case report.

Correspondence

Dr Kate Alfeld, Christchurch Public Hospital, Private Bag 4710, Christchurch.

Correspondence Email

kalfeld4@hotmail.com

Competing Interests

Nil.

  1. Sarantis H, Johnson G, Brown M, et al. Comprehensive detection and serotyping of human adenovirus by PCR and sequencing. Journal of Clinical Microbiology 2004; 42:3963–3969.
  2. Ghebremedhin B. Human adenovirus: Viral pathogen with increasing importance. European Journal of Microbiology and Immunology. 2014; Mar4(1):26–33.
  3. Dominguez O, Rojo P, de Las Heras S, et al. Clinical presentation and characteristics of pharyngeal adenovirus infections. Pediatr Infect Dis J 2005; 24(8):733–4.
  4. Foy HM, Cooney MK, Hatlen JB. Adenovirus type 3 epidemic associated with intermittent chlorination of a swimming pool. Archives of Environmental Health: An International Journal. 1968; Nov17(5):795–802.
  5. Artieda J, Pineiro L, Gonzalez MC, et al. A swimming pool-related outbreak of pharyngoconjunctival fever in children due to adenovirus type 4, Gipuzkoa, Spain, 2008. Eurosurveillance Feb 2009;14(8).
  6. Zhang L, Zhao N, Sha J, Wang C, et al. Virology and epidemiology analyses of global adenovirus-associated conjunctivitis outbreaks, 1953–2013. Epidemiology & Infection. 2016 Jun; 144(8):1661–72.
  7. Institute of Environmental Science and Research, New Zealand. (2018). Virology Annual Report 2015. [online] Available at: http://surv.esr.cri.nz/PDF_surveillance/Virology/VirAnnRpt/VirAnn2015.pdf [Accessed 1 Feb. 2018]
  8. Bennett JE, Dolin R, Blaser MJ. Mandell, Douglas, and Bennett’s principles and practice of infectious diseases. Philadelphia, PA:Elsevier/Saunders, 2015.
  9. Centers for Disease Control and Prevention. (2018). Adenovirus Vaccine Information Statement. [online] Available at: http://www.cdc.gov/vaccines/hcp/vis/vis-statements/adenovirus.html [Accessed 1 Feb. 2018]


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