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10 June 2015 - Case of the Week #354

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Thanks to Dr. Rajib Gupta, University of Tennessee Health Science Center and Dr. Jesse Jenkins, St. Jude Children's Research Hospital, Tennessee (USA), for contributing this case. To contribute a Case of the Week, follow the guidelines on our Case of the Week page.


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For more information, visit our New Books page.

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Case of the Week #354

Clinical History:
A 20 month old girl, post-stem cell transplant for MLL-rearranged acute myeloid leukemia (AML), presented with features of AML relapse, including bone marrow blasts, multifocal liver lesions and worsening kidney function. CT-guided liver biopsy was performed.

Micro images:

Figures 1-3, H&E



What is your diagnosis?































Diagnosis:
Adenovirus hepatitis with necrosis, post-stem cell transplant

Discussion:

An adenovirus immunostain confirmed the diagnosis:

Figures 4 and 5: adenovirus immunostain



Figure 1 is a panoramic view of the liver biopsy core, showing remnant hepatic tissue on either side of a large necrotic focus. Figure 2 shows a low power view of a few hepatocytes with dark purple-red nuclear inclusion bodies. Figure 3 shows a high power view of hepatocytes showing characteristic nuclear and cytoplasmic viral inclusion bodies. Figure 4 shows a high power view of nuclear and cytoplasmic positivity of adenovirus immunohistochemistry in the hepatocytes. The positive nuclear immunostain on the right side of the image corresponds to hepatocytes in the viable area while the immunostain on the left corresponds to dead hepatocytes within the necrotic area. Figure 5 is an oil immersion view of adenovirus immunostain in three affected hepatocytes.

Adenovirus is major cause of non-relapse morbidity and mortality after allogeneic hematopoietic stem cell transplantation for hematological malignancies (Intern Med 2006;45:975), and may be associated with fulminant hepatic failure (Case Rep Infect Dis 2012;2012:463569; see also Adenovirus hepatitis topic). The histology described in this case is classic.

Treatment with anti-virals, including Cidofovir, may be effective (Ann Hepatol 2014;13:827, Transplant Proc 2013;45:293, J Pediatr Hematol Oncol 2012;34:e298).

Nat Pernick, M.D., President
and Shivani Thakore, Associate Medical Editor
PathologyOutlines.com, Inc.
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Bingham Farms, Michigan (USA) 48025
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Email: NatPernick@gmail.com