Indications for Testing

  • Severe pneumonia in
    • Immunocompromised patient
    • Military recruit
    • Young child

Laboratory Testing

  • CDC diagnosis recommendations for adenovirus
  • Immunocompetent patients
    • Most cases are diagnosed based on clinical presentation alone
    • Antigen/DNA testing
      • DFA – respiratory specimens or nasopharyngeal swabs
      • RT PCR (qualitative) – highly sensitive; nasopharyngeal swabs
        • Standard of care for diagnosing adenovirus in tissue specimen
      • EIA – most useful in fecal samples for types 40, 41in gastroenteric disease
    • Serologic testing relies on demonstration of antibodies to group-specific antigens
      • Typically used in epidemiological studies
      • Often requires acute and convalescent sera
  • Immunocompromised patients
    • PCR
      • Standard screening tool for immunocompromised patients suspected of have adeno infection
      • Peripheral blood viremia appears to be the only site indicative of disseminated infection
    • Viral culture
      • Gold standard
      • Use of blood samples – not recommended due to lack of sensitivity
      • Slow growth makes early diagnosis difficult
      • Not recommended for most patients


  • Immunohistochemistry – adenovirus stain

Differential Diagnosis

Clinical Background

Adenoviruses usually cause mild, self-limiting respiratory illnesses, primarily in children. In immunocompromised patients, it may cause severe, fatal disease.


  • Prevalence
    • Causes 5-7% of respiratory infections in children
    • Year-round infection
    • Rarely fatal, but 50% of infants and young children have prolonged, intermittent disease
  • Age – usually <10 years (primary infection)
  • Transmission
    • Respiratory droplet transfer (fecal-oral)
    • Neonatal transmission following vaginal delivery (rare)
    • Nosocomial transmission reported


  • Double-stranded DNA virus; belongs to Adenoviridae family
  • Classified into 7 species, A-G – 60 serotypes identified
    • Types 4 and 7 are common in military recruit outbreaks
    • Type 14 commonly associated with severe and sometimes fatal respiratory illnesses

Risk Factors

  • Military service (recruit)
  • Immunocompromised status
  • Malnutrition in children <2 years
  • Transplant patients
    • Highest risk in allogeneic hematopoietic transplants with T-cell depletion, ATG treatment, or in the presence of graft versus host (grades III, IV)
    • Autologous transplants – much lower risk

Clinical Presentation

  • Immunocompetent patients
    • Most infections are mild, self-limited respiratory illness
    • Bronchiolitis, pneumonia (types 3, 7, 21)
    • Acute diarrhea (types 40, 41)
    • Hemorrhagic cystitis (types 7, 11, 21, 34, 35)
    • Epidemic keratoconjunctivitis (types 8, 19, 37)
    • Fatal adenovirus infections can occur in infants and immunocompromised adults (type 14)
    • Complications – hepatitis, acute colitis, cystitis, meningitis, encephalitis
  • Immunocompromised patients
    • Post-transplantation – solid organ
      • Usually 2-3 months after transplant
      • First symptoms – fever, enteritis, elevated transaminases, and pancytopenia
      • More severe disease in pediatric population
      • Often first manifests in organ of transplantation
    • Post-transplantation – hematopoiectic stem cell (HSCT)
      • Ranges from mild gastroenteritis, respiratory disease to severe disease (multi-organ failure)
      • Disseminated disease is frequently fatal

Indications for Laboratory Testing

  • Tests generally appear in the order most useful for common clinical situations
  • Click on number for test-specific information in the ARUP Laboratory Test Directory
Test Name and Number Recommended Use Limitations Follow Up
Respiratory Viruses DFA with Reflex to Viral Culture, Respiratory 0060281
Method: Direct Fluorescent Antibody Stain/Cell Culture

Order this test when the detection of respiratory viruses in addition to influenza is important

Detects influenza (A, B), parainfluenza (1, 2, 3), adenovirus, respiratory syncytial virus (RSV), and human metapneumovirus (hMPV)

Molecular methods are preferred for immunocompromised and hospitalized patients

For general inpatient workup of influenza-like illness, order the respiratory virus mini panel by PCR

Reflex pattern – if DFA is negative or inadequate, then a respiratory viral culture will be added

Respiratory Viruses Rapid Culture 2001504
Method: Cell Culture/Immunofluorescence

Detects common respiratory viruses (eg, influenza A and B; parainfluenza types 1, 2, 3; adenovirus; and RSV)

Offers improved turnaround time over respiratory viral culture

Molecular methods may offer improved sensitivity

Other viruses such as HSV, CMV, or human metapneumovirus not routinely detected in this culture

Limited sensitivity for adenovirus compared to conventional culture

Adenovirus, Quantitative PCR 2007192
Method: Quantitative Real-Time Polymerase Chain Reaction

Detect adenovirus

Monitor therapy

Highly sensitive and specific

Lower false-negative rate compared to DFA

Adenovirus by Qualitative PCR 2007473
Method: Qualitative Real-Time Polymerase Chain Reaction

Detect adenovirus

Highly sensitive and specific

Lower false-negative rate compared to DFA

Adenovirus 40-41 Antigens by EIA 0065066
Method: Qualitative Enzyme Immunoassay

Confirm adenovirus subtype most common in gastroenteritis presentation

Adenovirus by Immunohistochemistry 2003430
Method: Immunohistochemistry

Aid in histologic diagnosis of adenovirus

Stained and returned to client pathologist; if consultation required, contact anatomic pathology, surgical consult or hematopathology

Viral Culture, Non-Respiratory and Cytomegalovirus Rapid Culture 2006496
Method: Cell Culture/Immunofluorescence

Viruses that can be isolated – adenovirus, CMV, enterovirus, HSV, and VZV

Virus-specific tests are recommended

Molecular diagnostics are preferred for suspected invasive CMV

Slow growth; not ideal for acute identification

Additional Tests Available
Click the plus sign to expand the table of additional tests.
Test Name and NumberComments
Respiratory Viruses DFA 0060289
Method: Direct Fluorescent Antibody Stain

Not a preferred stand-alone test

Low sensitivity compared to culture; culture or PCR backup recommended 

Rotavirus and Adenovirus 40-41 Antigens 0065067
Method: Qualitative Enzyme Immunoassay

Confirm etiologic agent of gastroenteritis

Viral Culture, Respiratory and Cytomegalovirus Rapid Culture 2006497
Method: Cell Culture/Immunofluorescence

Viruses that can be isolated – adenovirus; CMV; enterovirus; HSV; influenza A and B; parainfluenza types 1,2, and 3; RSV; and VZV

Virus-specific tests are recommended

Molecular diagnostics are preferred for suspected invasive CMV