March 29, 2006
Adenoviral Non-Gonococcal Urethritis
By O'Mahony, C
Summary: Adenoviruses infect mucous membranes, including -on rare occasions the urethra. Adenoviruses should therefore be considered as yet another cause of chlamydia-negative non-gonococcal urethritis. The following case illustrates the dilemma posed in a patient with conjunctivitis and urethritis.
A middle-aged man attended clinic in March 2004. He complained of a 10-day history of intense dysuria, frequency and reddening of the tip of the penis. He also complained that both eyes were feeling gritty the last day. Four days earlier, he had been to his general practitioner who had diagnosed a urinary tract infection and had given him norfloxacin 400 mg twice daily for three days. He was married, but did have occasional oral sex from sex workers. Gram- stained urethral smear showed +++ pus cells. He had the usual swabs for gonorrhoea and chlamydia, and a midstream urine sample sent for analysis. He was given 1 g azithromycin and told to call in 10 days. However, three days later, he re-attended with worsening of symptoms. The urethritis was worse and both eyes were now inflamed. Further discussion elicited a history of possible food poisoning, three months earlier, with diarrhoea for a week; so there was a concern about a Reiter's type syndrome, although there was no arthritis. He was referred immediately to an ophthalmologist for reassurance about possible uveitis. He was seen straight away and had swabs done, and the ophthalmologist prescribed him two weeks of doxycycline 100 mg twice daily. As this case was unusual, I took photos of the eyes and the penis as there was still considerable urethritis, despite the patient having had norfloxacin, azithromycin and doxycycline (Figures 1, 2 and 3). A week later, he called to say that his wife and child also had conjunctivitis then. One of his eye swabs from ophthalmology was reported as detecting adenovirus. By the time he next attended clinic after four days, his symptoms had started to resolve. On examination, there was no residual urethritis, and a urethral swab for adenovirus at that late stage was negative. His wife was seen, but not treated, as this was assumed to be an adenovirus urethritis.
There are many causes of chlamydia-negative non-gonococcal urethritis (NGU). It is not unusual to find herpes virus causing intense dysuria if there happens to be an ulcer in the urethra, and it is no surprise that adenovirus infection is also capable of causing a urethritis. Azariah and Reid1 reviewed the literature and also described six cases. Adenovirus can occasionally be isolated from the urethra of men with no signs or symptoms of urethritis, and many situations can therefore be regarded as simple colonization. Oral sex is an easy way of transmitting respiratory adenovirus to the urethra, and oral sex is a known risk factor for NGU.2 Adenoviral conjunctivitis is highly contagious and it is not surprising that other family members rapidly get infected (hence, the term epidemic keratoconjunctivitis). Swenson et al.3 found urethral adenovirus in 20 male patients, attending an sexually transmitted disease (STD) clinic, of whom, 13 had NGU with no other pathogen found.
Figure 1 Marked inflammation of the meatus with a mucoid discharge
Figure 2 Bilateral conjunctivitis
Figure 3 Obvious conjunctivitis extending right to the corneal margin, so there was a concern about uveitis
A rapid tissue culture test for adenovirus is available - Direct Early Antigen Fixed Focus (DEAFF). A urethral swab is sent in viral transport media for DEAFF and culture. It is necessary to highlight that it is an adenovirus request as there is a risk that the laboratory technicians will assume a urethral viral swab is for herpes culture and may process it inappropriately.
In conclusion, adenovirus as the cause of urethritis should be considered in men with conjunctivitis, intense dysuria, a urethral Gram stain showing inflammation, subsequent negative tests for gonorrhoea and chlamydia, and no response to azithromycin or doxycycline.
1 Azariah S, Reid M. Adenovirus and non-gonococcal urethritis. Int J STD AIDS 2000;11:548-50
2 Hernandez-Aguado I, Alvarez-Dardet C, GiIi M, Perea EJ, Camcho F. Oral sex as a risk factor for chlamydia-negative ureaplasm- negative non-gonococcal urethritis. Sex Transm Dis 1987;15:100-2
3 Swenson PD, Lowens MS, Celum CL, Hierholzer JC. Adenovirus types 2, 8 and 37 associated with genital infections in patients attending a sexually transmitted disease clinic. J Clin Microbiol 1995;33:2728-31
(Accepted 26 January 2005)
C O'Mahony MD FRCP
Sexual Health Department, Countess of Chester Hospital, NHS Foundation Trust, Chester CH2 1UL, UK
Copyright Royal Society of Medicine Press Ltd. Mar 2006