{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T18:43:43Z","timestamp":1787769823324,"version":"build-2784847793"},"reference-count":45,"publisher":"MDPI AG","issue":"12","license":[{"start":{"date-parts":[[2024,12,17]],"date-time":"2024-12-17T00:00:00Z","timestamp":1734393600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Pathogens"],"abstract":"<jats:p>Human adenoviruses (HAdVs) are known to be highly contagious pathogens. They are commonly associated with mild respiratory infections in young children but can also cause severe life-threatening infections. Human adenovirus types 4 and 7 have frequently been reported to cause pneumonia in immunocompetent youths and adults. In this retrospective study, we analyzed the clinical, laboratory, radiological, and microbiological features, as well as the treatment and outcomes of an adenovirus outbreak in 185 patients who were admitted to the Emergency Unit of the Departments of Infectious Diseases and Pediatrics, University Hospital of Split, Croatia, between October 2022 and April 2023. An unusual increase in the frequency of adenovirus pneumonia was observed, especially in adults, followed by respiratory failure and complications such as pulmonary embolism. The most common chest X-ray findings were unilateral patchy opacity and unilateral reticulations (11.6%), followed by unilateral lobar pneumonia (7.1%). The predominant CT presentation was unilateral lobar pneumonia with multiple patchy ground glass opacities (23.5%) or lobar pneumonia with mixed opacities (17.6%). We found a low correlation between Brixia score and C-reactive protein in adults and no correlation in children. Adenovirus type 7 was almost exclusively isolated from patients with pneumonia. Most of our patients with severe or critical adenovirus pneumonia were immunocompetent adults without any medical history. So far, only a few studies have presented the radiological features of HAdV pneumonia, which generally did not reveal lobar pneumonia in a substantial percentage. Our research also demonstrated an unusual presentation of adenovirus infection complicated with pulmonary embolism, which has rarely been reported in previous studies. The aforementioned HAdV outbreak indicates the necessity for further research, especially in the context of effective antiviral therapy and infection prevention.<\/jats:p>","DOI":"10.3390\/pathogens13121114","type":"journal-article","created":{"date-parts":[[2024,12,17]],"date-time":"2024-12-17T03:46:02Z","timestamp":1734407162000},"page":"1114","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Clinical and Radiological Features of an Adenovirus Type 7 Outbreak in Split-Dalmatia County, Croatia, 2022\u20132023"],"prefix":"10.3390","volume":"13","author":[{"given":"Antea","family":"Trogrlic","sequence":"first","affiliation":[{"name":"Department of Infectious Diseases, University Hospital of Split, Spinciceva 1, 21000 Split, Croatia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7610-4891","authenticated-orcid":false,"given":"Dina","family":"Mrcela","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, University Hospital of Split, Spinciceva 1, 21000 Split, Croatia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1362-2901","authenticated-orcid":false,"given":"Danijela","family":"Budimir Mrsic","sequence":"additional","affiliation":[{"name":"Department of Diagnostic and Interventional Radiology, University Hospital of Split, Spinciceva 1, 21000 Split, Croatia"},{"name":"School of Medicine, University of Split, Soltanska 2a, 21000 Split, Croatia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ivana","family":"Jukic","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, University Hospital of Split, Spinciceva 1, 21000 Split, Croatia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sanda","family":"Sardelic","sequence":"additional","affiliation":[{"name":"Department of Microbiology and Parasitology, University Hospital of Split, Spinciceva 1, 21000 Split, Croatia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2518-522X","authenticated-orcid":false,"given":"Irena","family":"Tabain","sequence":"additional","affiliation":[{"name":"Croatian Institute of Public Health, Rockefellerova 7, 10000 Zagreb, Croatia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9078-1773","authenticated-orcid":false,"given":"\u017deljka","family":"Hruskar","sequence":"additional","affiliation":[{"name":"Croatian Institute of Public Health, Rockefellerova 7, 10000 Zagreb, Croatia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0879-3554","authenticated-orcid":false,"given":"Diana","family":"Nonkovic","sequence":"additional","affiliation":[{"name":"Teaching Institute for Public Health of Split-Dalmatia County, Vukovarska 46, 21000 Split, Croatia"},{"name":"Department of Health Studies, University of Split, R. Boskovica 35, 21000 Split, Croatia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9469-9278","authenticated-orcid":false,"given":"Josko","family":"Markic","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, University Hospital of Split, Spinciceva 1, 21000 Split, Croatia"},{"name":"School of Medicine, University of Split, Soltanska 2a, 21000 Split, Croatia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8878-7164","authenticated-orcid":false,"given":"Mirela","family":"Pavicic Ivelja","sequence":"additional","affiliation":[{"name":"Department of Infectious Diseases, University Hospital of Split, Spinciceva 1, 21000 Split, Croatia"},{"name":"Department of Health Studies, University of Split, R. Boskovica 35, 21000 Split, Croatia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2024,12,17]]},"reference":[{"key":"ref_1","unstructured":"Usman, N., and Suarez, M. (2024, September 15). Adenovirus, Available online: https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK559072\/."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"217","DOI":"10.1128\/microbiolspec.DMIH2-0020-2015","article-title":"Adenovirus","volume":"4","author":"Ison","year":"2016","journal-title":"Microbiol. Spectr."},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Khanal, S., Ghimire, P., and Dhamoon, A.S. (2018). The Repertoire of Adenovirus in Human Disease: The Innocuous to the Deadly. Biomedicines, 6.","DOI":"10.20944\/preprints201801.0267.v1"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"eabd9149","DOI":"10.1126\/science.abd9149","article-title":"Airborne transmission of respiratory viruses","volume":"373","author":"Wang","year":"2021","journal-title":"Science"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"89","DOI":"10.1016\/j.ijid.2018.08.009","article-title":"A swimming pool-associated outbreak of pharyngoconjunctival fever caused by human adenovirus type 4 in Beijing, China","volume":"75","author":"Li","year":"2018","journal-title":"Int. J. Infect. Dis."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"341","DOI":"10.1002\/dc.2840120411","article-title":"Neonatal adenovirus infection: A case report with in situ hybridization confirmation of ascending intrauterine infection","volume":"12","author":"Montone","year":"1995","journal-title":"Diagn. Cytopathol."},{"key":"ref_7","first-page":"1547","article-title":"Serological studies of adenoviral hepatitis following pediatric liver transplantation","volume":"22","author":"Koneru","year":"1990","journal-title":"Transpl. Proc."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"64","DOI":"10.1093\/pubmed\/fdu009","article-title":"Prison and community outbreak of severe respiratory infection due to adenovirus type 14p1 in Tayside, UK","volume":"37","author":"Parcell","year":"2015","journal-title":"J. Public Health"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1992","DOI":"10.1093\/cid\/ciaa465","article-title":"Outbreaks of Adenovirus-associated Respiratory Illness on 5 College Campuses in the United States, 2018\u20132019","volume":"72","author":"Kujawski","year":"2021","journal-title":"Clin. Infect. Dis."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"586","DOI":"10.1055\/s-0036-1584923","article-title":"Adenovirus: Epidemiology, Global Spread of Novel Serotypes, and Advances in Treatment and Prevention","volume":"37","author":"Lynch","year":"2016","journal-title":"Semin. Respir. Crit. Care Med."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"441","DOI":"10.1128\/CMR.00116-13","article-title":"Adenovirus infections in immunocompetent and immunocompromised patients","volume":"27","author":"Lion","year":"2014","journal-title":"Clin. Microbiol. Rev."},{"key":"ref_12","first-page":"73","article-title":"Adenovirus: Ocular manifestations","volume":"33","author":"Hoffman","year":"2020","journal-title":"Community Eye Health"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"105244","DOI":"10.1016\/j.jcv.2022.105244","article-title":"Clinical features, treatment and outcomes of an outbreak of type 7 adenovirus pneumonia in centralized residence young adults","volume":"154","author":"Shen","year":"2022","journal-title":"J. Clin. Virol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1436","DOI":"10.1177\/0885066620960687","article-title":"Comparative study on the effect of cidofovir treatment for severe adenovirus pneumonia","volume":"36","author":"Moon","year":"2023","journal-title":"J. Intensive Care Med."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Yoon, B.W., Song, Y.G., and Lee, S.H. (2017). Severe community-acquired adenovirus pneumonia treated with oral ribavirin: A case report. BMC Res. Notes, 10.","DOI":"10.1186\/s13104-016-2370-2"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"e01237-23","DOI":"10.1128\/jcm.01237-23","article-title":"Increased circulation of human adenovirus in 2023: An investigation of the cir-culating genotypes, upper respiratory viral loads, and hospital admissions in a large academic medical center","volume":"62","author":"Abdullah","year":"2024","journal-title":"J. Clin. Microbiol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"581","DOI":"10.3343\/alm.2023.0484","article-title":"Adenovirus Activity After the COVID-19 Pandemic in South Korea: Analysis of National Surveillance Data","volume":"44","author":"Lee","year":"2024","journal-title":"Ann. Lab. Med."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"4","DOI":"10.1016\/j.molmed.2022.10.001","article-title":"Adenoviruses in medicine: Innocuous pathogen, predator, or partner","volume":"29","author":"MacNeil","year":"2023","journal-title":"Trends Mol. Med."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"e939578","DOI":"10.12659\/MSM.939578","article-title":"Factors Associated with Severe Adenovirus Pneumonia in Children: A Retrospective Study from Guangzhou, China (2017\u20132019)","volume":"29","author":"Hong","year":"2023","journal-title":"Med. Sci. Monit."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"ofae192","DOI":"10.1093\/ofid\/ofae192","article-title":"Detection of a Human Adenovirus Outbreak, Including Some Critical Infections, Using Multipathogen Testing at a Large University, September 2022\u2013January 2023","volume":"11","author":"Montgomery","year":"2024","journal-title":"Open Forum Infect. Dis."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Nukovic, J.A., Opancina, V., Zdravkovic, N., Prodanovic, N., Pejcic, A., Opancina, M., Nukovic, J.J., Vojinovic, R., Dulovic, D., and Jukovic, F. (2023). Brixia Chest X-ray Score, Laboratory Parameters and Vaccination Status for Prediction of Mortality in COVID-19 Hospitalized Patients. Diagnostics, 13.","DOI":"10.3390\/diagnostics13122122"},{"key":"ref_22","first-page":"15","article-title":"Brixia Chest X-ray Scoring System in Critically Ill Patients with COVID-19 Pneumonia for Determining Outcomes","volume":"15","author":"Agrawal","year":"2021","journal-title":"J. Clin. Diagn. Res."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"202","DOI":"10.1111\/resp.14150_319","article-title":"The relationship of chest X-ray in COVID-19 patients towards disease severity at Arifin Achmad Regional General Hospital, Riau Province","volume":"26","author":"Rahman","year":"2021","journal-title":"Respirology"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"254","DOI":"10.1186\/s43055-020-00368-y","article-title":"The mean severity score and its correlation with common computed tomography chest manifestations in Egyptian patients with COVID-2019 pneumonia","volume":"51","author":"Hafez","year":"2020","journal-title":"Egypt. J. Radiol. Nucl. Med."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"166","DOI":"10.1186\/s43055-022-00832-x","article-title":"Correlation of chest CT severity score with clinical parameters in COVID-19 pulmonary disease in a tertiary care hospital in Delhi during the pandemic period","volume":"53","author":"Sharma","year":"2022","journal-title":"Egypt. J. Radiol. Nucl. Med."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"373","DOI":"10.1016\/0021-9681(87)90171-8","article-title":"A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation","volume":"40","author":"Charlson","year":"1987","journal-title":"J. Chronic. Dis."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1120","DOI":"10.1086\/522188","article-title":"Genotype prevalence and risk factors for severe clinical adenovirus infection, United States 2004-2006","volume":"45","author":"Gray","year":"2007","journal-title":"Clin. Infect. Dis."},{"key":"ref_28","unstructured":"Baron, S. (2024, September 15). Adenovirus, Medical Microbiology, Available online: https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK8503\/."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"111","DOI":"10.1128\/JCM.39.1.111-118.2001","article-title":"Respiratory viral infections among pediatric inpatients and outpatients IN Tawain from 1997 to 1999","volume":"39","author":"Tsai","year":"2001","journal-title":"J. Clin. Microbiol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"e776","DOI":"10.1097\/MD.0000000000000776","article-title":"Adenovirus pneumonia complicated with acute respiratory distress syndrome: A case report","volume":"94","author":"Hung","year":"2015","journal-title":"Medicine"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"680","DOI":"10.1097\/INF.0b013e318256605e","article-title":"Adenovirus respiratory infections in hospitalized children: Clinical findings in relation to species and serotypes","volume":"31","author":"Tabain","year":"2012","journal-title":"Pediatr. Infect. Dis. J."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1044","DOI":"10.3201\/eid2206.151898","article-title":"Human Adenovirus Associated with severe Respiratory Infection, Oregon, USA, 2013\u20132014","volume":"22","author":"Scott","year":"2016","journal-title":"Emerg. Infect. Dis."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1","DOI":"10.3390\/pediatric15010001","article-title":"Different Clinical Manifestations of Adenoviral Infection Confirmed Using Point-of-Care Testing in a Gropu of Hospitalized Children","volume":"15","author":"Ptak","year":"2023","journal-title":"Pediatr. Rep."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"620","DOI":"10.1056\/NEJMoa2206294","article-title":"A Case Series of Children with Acute Hepatitis and Human Adenovirus Infection","volume":"387","author":"Shiau","year":"2022","journal-title":"N. Engl. J. Med."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"719","DOI":"10.1148\/rg.2018170048","article-title":"Radiographic and CT Features of Viral Pneumonia","volume":"38","author":"Koo","year":"2018","journal-title":"Radiographics"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1343","DOI":"10.1111\/crj.13439","article-title":"Clinical and CT findings of adenovirus pneumonia in immunocompetent adults","volume":"15","author":"Zhang","year":"2021","journal-title":"Clin. Respir. J."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1288","DOI":"10.2214\/AJR.05.0128","article-title":"Adenovirus pneumonia in adults: Radiographic and high-resolution CT findings in five patients","volume":"186","author":"Chong","year":"2006","journal-title":"AJR Am. J. Roentgenol."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"848","DOI":"10.21037\/jtd.2016.03.38","article-title":"Severe adenovirus community-acquired pneumonia in immunocompetent adults: Chest radiographic and CT findings","volume":"8","author":"Tan","year":"2016","journal-title":"J. Thorac. Dis."},{"key":"ref_39","doi-asserted-by":"crossref","unstructured":"Mao, J., Zhao, H., and Cui, N. (2022). Case report: An unusual case of multisite embolism in a patient with adenovirus pneumoniae. Front. Med., 9.","DOI":"10.3389\/fmed.2022.939102"},{"key":"ref_40","first-page":"345","article-title":"Serum C-reactive protein in children with adenovirus infection","volume":"132","author":"Appenzeller","year":"2002","journal-title":"Swiss Med. Wkly."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"3489","DOI":"10.1007\/s00431-024-05615-2","article-title":"Determinants of antibiotic prescription in children with adenovirus respiratory tract infections","volume":"183","author":"Buonsenso","year":"2024","journal-title":"Eur. J. Pediatr."},{"key":"ref_42","doi-asserted-by":"crossref","unstructured":"Stein, M., Shapira, M., Bamberger, E., Chistyakov, I., Dumov, D., Srugo, I., Stein, M., Bont, L.J., and Klein, A. (2022). BV score differentiates viral from bacterial-viral co-infection in adenovirus PCR positive children. Front. Pediatr., 10.","DOI":"10.3389\/fped.2022.990750"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1620\/tjem.209.69","article-title":"Pulse methylprednisolone therapy in type 3 adenovirus pneumonia with hypercytokinemia","volume":"209","author":"Takahashi","year":"2006","journal-title":"Tohoku J. Exp. Med."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"473","DOI":"10.1007\/s00005-011-0148-8","article-title":"Disseminated adenovirus disease in immunocompromised patient successfully treated with oral ribavirin: A case report","volume":"59","author":"Ulrych","year":"2011","journal-title":"Arch. Immunol. Ther. Exp."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"e20191632","DOI":"10.1542\/peds.2019-1632","article-title":"Successful Use of Cidofovir in an Immunocompetent Child With Severe Adenoviral Sepsis","volume":"145","author":"Alcamo","year":"2020","journal-title":"Pediatrics"}],"container-title":["Pathogens"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2076-0817\/13\/12\/1114\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T16:53:31Z","timestamp":1760115211000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2076-0817\/13\/12\/1114"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,12,17]]},"references-count":45,"journal-issue":{"issue":"12","published-online":{"date-parts":[[2024,12]]}},"alternative-id":["pathogens13121114"],"URL":"https:\/\/doi.org\/10.3390\/pathogens13121114","relation":{},"ISSN":["2076-0817"],"issn-type":[{"value":"2076-0817","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,12,17]]}}}