Late-Onset Adenovirus-Induced Achalasia in a Kidney Transplant Recipient: A Case Report

BACKGROUND Adenovirus infection in kidney transplant recipients, although rare, represents a potentially life-threatening complication that typically manifests early after transplantation. Late-onset adenovirus infection is uncommon and presents substantial diagnostic and therapeutic challenges, particularly in cases of atypical organ involvement. Esophageal involvement is exceptionally rare and has not been extensively characterized in solid-organ transplant recipients. CASE REPORT A 60-year-old male kidney transplant recipient presented with a 1-week history of dysuria, gross hematuria, diarrhea, and worsening graft function 5 years after transplantation. Progressive dysphagia developed after admission. Laboratory testing confirmed adenovirus infection in the blood, with a viral load of 779 000 IU/mL. Adenovirus was also detected in urine and stool samples, whereas cytomegalovirus and polyomavirus testing yielded negative results. Gastroscopy and barium swallow studies demonstrated achalasia-like features. Esophageal biopsy specimens did not show viral cytopathic changes. Management consisted of immunosuppression reduction, intravenous immunoglobulin administration, and low-dose cidofovir therapy. Clinical and virologic recovery was achieved within 3 weeks, with complete resolution of gastrointestinal symptoms and stabilization of graft function. CONCLUSIONS This case underscores the atypical late presentation of adenovirus infection in a kidney transplant recipient and illustrates the potential for extremely rare esophageal involvement manifesting as achalasia. Despite the absence of direct viral confirmation in esophageal tissue, the clinical course and therapeutic response support adenovirus as the most likely etiology. Early recognition, confirmation by polymerase chain reaction testing, and timely immunosuppression adjustment combined with antiviral therapy are essential to optimize patient outcomes.