Management of Adenovirus in Children
Most adenovirus infections in immunocompetent children are self-limited and require only supportive care, but severely ill or immunocompromised children with life-threatening disease should be treated with cidofovir despite its nephrotoxicity risk. 1
Risk Stratification and Recognition of Severe Disease
Identify children at high risk for severe outcomes by assessing:
- Age under 2 years with dyspnea and systemic toxic symptoms 2
- Immunocompromised status (transplant recipients, HIV, severe combined immunodeficiency) where fatality rates can exceed 50% without treatment 3
- Radiographic findings showing lobar/segmental pneumonia, atelectasis, emphysema, or pleural effusion 2, 4
- Laboratory abnormalities including leukocytosis or leukopenia, significantly elevated CRP and procalcitonin, anemia, and coagulopathy 2, 4
- Extrapulmonary manifestations such as hepatitis, encephalitis, hemorrhagic cystitis, or conjunctivitis indicating disseminated disease 4, 3
Critical pitfall: Severe adenovirus infection may mimic bacterial infection with rapid progression despite antibiotic therapy—this clinical pattern combined with unusual extrapulmonary symptoms should trigger consideration of adenoviral etiology 4
Treatment Approach
Immunocompetent Children with Mild-Moderate Disease
- Supportive care only including hydration, antipyretics, and respiratory support as needed 1
- No specific antiviral therapy is indicated for self-limited gastroenteritis or upper respiratory infections 1
- Monitor for clinical deterioration over 7-10 days (typical illness duration) 1
Severely Ill or Immunocompromised Children
Cidofovir is the treatment of choice for life-threatening adenovirus infections despite lack of randomized controlled trials 1, 3:
- Dosing regimen: 5 mg/kg IV once weekly for 2 weeks, then once every other week 1
- Alternative low-dose regimen: 1 mg/kg three times weekly 1
- Mandatory monitoring: Renal function must be closely monitored due to considerable nephrotoxicity risk 1
- Consider treatment in children requiring intensive care, mechanical ventilation, or with disseminated disease 4, 5
Evidence strength: While only case reports and case series support cidofovir use in children, it has demonstrated efficacy in pediatric hematology outbreaks with 7 patients successfully treated 1. In the absence of alternatives and given mortality rates exceeding 50% in untreated severe cases, early treatment is justified 3, 5
Respiratory Support
- Mechanical ventilation may be required in severe pneumonia—note this is an independent risk factor for post-infectious bronchiolitis obliterans (PIBO) 2
- Bronchoscopy can be utilized for airway management in severe cases 2
- Hypoxemia and hypercapnia are associated with mortality and warrant aggressive respiratory support 2
Immunomodulatory Therapy
- Consider in severe cases with hyperinflammatory response 2
- Caution with corticosteroids: Intravenous steroid use is an independent risk factor for PIBO development 2
- Blood purification may be considered in critically ill patients 2
Monitoring and Follow-up
- Viral load monitoring in immunocompromised patients (particularly transplant recipients) through serial stool samples or peripheral blood can trigger early treatment initiation 6
- Duration of fever correlates with PIBO risk—prolonged fever warrants closer monitoring 2
- Post-discharge surveillance: 62.5% of survivors from severe infection develop bronchiolitis obliterans and/or organizing pneumonia at 3 months 4
- Male gender is an additional independent risk factor for PIBO 2
Infection Control
- Highly contagious period: Consider patients infectious for 10-14 days from symptom onset 1
- Hand hygiene: Soap and water (not sanitizer alone) is essential as adenovirus survives on surfaces for up to 28 days 1
- Healthcare settings: Use dilute bleach (1:10 sodium hypochlorite) for equipment disinfection; 70% isopropyl alcohol is inadequate 1
- Isolate infected children in hospitals and daycare settings to prevent outbreaks 1
Prognostic Factors
Poor outcomes are associated with: