Breaking the Paradigm: A Case of Fatal Adenovirus Hepatitis in an Immunocompetent Adult

Introduction: Adenovirus hepatitis is a rare but potentially serious liver infection typically seen in immunocompromised individuals. During the COVID-19 pandemic in 2022, a rise in adenovirus hepatitis outbreaks have been primarily reported in children leading to a CDC health advisory. In certain immunocompromised individuals or those with pre-existing liver conditions, adenovirus hepatitis is often a diagnosis of exclusion. We report an intriguing case of acute liver failure caused by adenovirus resulting in mortality in immunocompetent male with no prior liver disease.


Description: A 74-year-old male with a past medical history of coronary artery disease with stents, chronic back pain, previous history of alcohol use initially presenting with altered mental status. Lab findings were consistent with acute liver failure complicated by alcohol level of 11, worsening kidney function, lactic acidosis, and coagulopathy. Acute hepatitis panel revealed reactive HepB Surface Antibody and Hepatitis A Antibody. CT of abdomen and pelvis revealed signs of an infectious or inflammatory process in the upper right quadrant. The patient experienced clinical deterioration within 24 hours and was not a candidate for liver transplant evaluation given severe sepsis. Postmortem autopsy demonstrated sub massive hepatic necrosis, severe myocardial hypertrophy, severe hypertensive renal disease, acute congestive heart failure, severe pulmonary congestion and edema.The presence of acute adenovirus hepatitis with massive necrosis, involving up to 85% of the liver was determined to be the cause of death for this patient.


Discussion: Our patient’s lack of predisposing conditions makes the diagnosis more challenging and raises questions about the unusual pathogenesis or possible underlying immunocompromised status. However, an extensive immunological workup including postmortem testing were all negative. Currently, the recommended guidelines for diagnosis and management for adults with elevated liver enzymes regardless of immune status include viral serologies and PCR testing for hepatitis, herpes simplex virus, varicella zoster virus, and HIV. There are currently no established guidelines regarding adenovirus testing in acute liver failure adults. Given its rarity, adenovirus is typically a diagnosis of exclusion.