A case series of children with adenovirus pneumonia: three-year experiences in a tertiary PICU

Severe Adenovirus Pneumonia Masked by Influenza Virus in an 11-Year-Old Child: A Case Report

Background

Adenovirus pneumonia progresses rapidly, with a high rate of progression to severe pneumonia, but the early clinical manifestations lack specificity and are not easy to be recognized.

Methods

Reviewing the relevant literatures, we studied and summarized the early recognition, clinical features and treatment outlook of severe adenovirus pneumonia Case Presentation: An 11-year-old child with community-acquired pneumonia, with influenza A antigen positive by colloidal gold, which further developed into acute respiratory distress syndrome after hospitalization. Three days later, adenovirus was detected positively by PCR of throat swab and diagnosed as severe adenovirus pneumonia. After aggressive treatment, her condition improved and was discharged from the hospital.

Conclusion

Clinically, adenovirus combined with influenza virus infection is uncommon, and adenovirus infection is even rarer in adolescent children.

Risk factors for secondary infection after liver failure and effect of comprehensive nursing intervention

BACKGROUND

In patients with liver failure (LF), the high rate of secondary infections, which are associated with poor prognosis, highlights the clinical significance of understanding the underlying risk factors and implementing targeted intervention programs.

AIM

To investigate risk factors for secondary infections in patients with LF and evaluate the effectiveness of comprehensive nursing interventions.

METHODS

This retrospective study included 64 patients with LF, including 32 with and 32 without secondary infections. A questionnaire was used to collect data on age; laboratory parameters, including total and direct bilirubin, prothrombin time, blood ammonia, and other biochemical parameters; invasive procedures; and complications. Patients with secondary infections received comprehensive nursing intervention in addition to routine nursing care, whereas those without secondary infections received only routine nursing care to compare the effect of nursing intervention on outcomes.

RESULTS

The infection rate, which was not associated with age or complications, was significantly associated with biochemical parameters and invasive procedures (P < 0.05). The infection rate was 61.6% in patients who had undergone invasive procedures and 32.1% in those who had not undergone invasive procedures during the hospital stay. The infection rate was also significantly associated with the type of LF (P < 0.05), with the lowest rate observed in patients with acute LF and the highest rate observed in those with subacute LF. The nursing satisfaction rate was 58.3% in the uninfected group and 91.7% in the infected group, indicating significantly higher satisfaction in the infected group (P < 0.05).

CONCLUSION

In patients with LF, the rate of secondary infections was high and associated with biochemical parameters and type of LF. Comprehensive nursing intervention can improve patient satisfaction.

Epidemiology of Adenovirus Infection in Hospitalized Children in the United States From 1997 to 2019

OBJECTIVE

The study aimed to explore the prevalence, clinical features, resource utilization, temporal trends and outcomes associated with adenoviral infections in hospitalized children.

METHODS

A retrospective analysis using the Healthcare Cost and Utilization Project's Kids' Inpatient Database from 1997 to 2019 was performed. Children 29 days to 17 years of age with adenoviral infection were selected. Chi-square, Kruskal-Wallis tests, linear trend analysis and multivariable analysis were used for data analysis.

RESULTS

A total of 40,135 children under 18 years of age with adenoviral infection were discharged in the United States with an overall prevalence of 18.9 per 10,000 discharges and 6.9 children per 100,000 population. By linear trend analysis, the hospitalization rate has significantly increased with the highest prevalence in 2019. Adenoviral infection was more prevalent in Black children, in winter months, in the Midwest region, in children with government insurance and in the lowest income quartile. The majority (85%) of adenovirus-related hospitalizations occurred under 6 years of age. Mechanical ventilation, extracorporeal membrane oxygenation support, acute kidney injury and liver failure were documented in 11.9%, 0.4%, 2.7% and 0.4%, respectively. The overall case fatality rate was 1.4%, which decreased from 1997 to 2019 ( P < 0.05). By regression analysis, an increased mortality rate was associated with the need for mechanical ventilation, the presence of complex chronic conditions, immune deficiency, central nervous system infection and pneumonia/bronchiolitis.

CONCLUSIONS

Most human adenovirus infections occur in children under 6 years of age and cause mild illness. Human adenovirus can lead to serious illness in children with complex chronic conditions and immune deficiency conditions.

PD1+CD4+ T cells promote receptor editing and suppress autoreactivity of CD19+CD21low B cells within the lower respiratory airways in adenovirus pneumonia

Human adenovirus (HAdV) pneumonia poses a major health burden for young children, however, factors that contribute to disease severity remain elusive. We analyzed immune cells from bronchoalveolar lavage (BAL) of children with HAdV pneumonia and found that CD19+CD21low B cells were significantly enriched in the BAL and were associated with increased autoantibody concentrations and disease severity. Myeloid cells, PD-1+CD4+ T helper cells and CD21low B cells formed tertiary lymphoid structures within the respiratory tracts. Myeloid cells promoted autoantibody production by expressing high amounts of B cell activating factor (BAFF). In contrast, PD-1+CD4+ T helper cells induced production of IgG1 and IgG3 antibodies but suppressed autoreactive IgGs by initiating B cell receptor editing. In summary, this study reveals cellular components involved in protective versus autoreactive immune pathways in the respiratory tract, and these findings provide potential therapeutic targets for severe HAdV lower respiratory tract infections.

Adenovirus and Mycoplasma pneumoniae co-infection as a risk factor for severe community-acquired pneumonia in children

Background

To investigate the pathogenic characteristics and risk factors of pediatric severe community-acquired pneumonia (CAP).

Methods

We retrospectively analyzed the clinical data of hospitalized children with severe CAP from April 2014 to June 2019 in China. Data of age, sex and pathogenic results were collected: bacterial and fungal cultures, respiratory viruses from sputum or bronchoalveolar lavage fluid (BALF), serum Mycoplasma pneumoniae (MP)-IgM and Chlamydia Pneumoniae-IgM, and BALF or blood (1-3)-β-D-glucan/galactomannan test.

Results

A total of 679 children with severe CAP were included in the analysis. The number of cases infected with MP was higher in males than in females. There were significant differences between the ≤1-year and >1-year groups in terms of pathogen. The top three bacteria cultured were Haemophilus influenzae (57/679, 8.4%), Streptococcus pneumoniae (50/679, 7.4%), and Pseudomonas aeruginosa (25/679, 3.7%). The top three viruses detected were adenovirus (AdV, 124/679, 18.3%), respiratory syncytial virus (24/679, 3.5%), and parainfluenza virus (21/679, 3.1%). AdV and MP were the leading pathogens, detected in 18.3% and 32.6% cases, respectively. MP infection increased the risk of AdV infection (OR 3.77, p < 0.0001). MP infection was a risk factor for severe AdV-infected pneumonia, while sex, age, bacteria, Chlamydia Pneumoniae, fungal, and AdV infections were risk factors for severe MP-infected pneumonia.

Conclusions

AdV and MP were dominant pathogens in children with severe CAP. AdV and MP infection predisposed each other to develop severe illness. AdV-MP co-infection may lead to severe pneumonia.

Molecular epidemiology and phylogenetic analyses of human adenovirus in pediatric patients with acute respiratory infections from Hangzhou during COVID-19 pandemic

Background

Acute Respiratory Infections (ARIs) are a major cause of morbidity and mortality worldwide. Human Adenovirus (HAdV), responsible for 5%-10% of children's ARIs, is one of the most prevalent pathogens. Our study aimed to analyze the epidemiology and phylogenesis of HAdV in pediatric patients with ARIs in Hangzhou during the COVID-19 pandemic.

Method

Between November 2020 and March 2021, we collected 1,442 nasopharyngeal swabs from children with ARIs at Children's Hospital, Zhejiang University School of Medicine. Epidemiological statistics, phylogenetic and amino acid (AA) mutation analysis were conducted.

Results

Our findings revealed that 386 (26.77%) samples tested positive for HAdV, with the highest rate in children aged 6-18 years and the lowest in children aged 0-1 year, indicating a different age preference of HAdV compared with pre-pandemic period. Outpatients had a significantly higher positive rate than inpatients. Moreover, patients with HAdV-coinfection exhibited more severe clinical symptoms than those with HAdV-single infection. Our phylogenetic analysis demonstrated that species HAdV-C (type 1, 2, 6) were the predominant circulating strains in Hangzhou during the COVID-19 pandemic. Further AA mutation analysis identified seventeen mutations of particular concern for biological characterization.

Conclusion

In conclusion, our study provides valuable epidemiological and molecular data that will aid in epidemiological surveillance, antiviral therapies and the development of specific vaccine types, leading to improve public health.

Factors Associated with Severe Adenovirus Pneumonia in Children: A Retrospective Study from Guangzhou, China (2017-2019)

BACKGROUND Adenovirus infections are prevalent in children, typically presenting with mild or asymptomatic symptoms. However, some children develop severe pneumonia necessitating hospitalization. This retrospective study aimed to identify risk factors associated with severe adenovirus pneumonia in children. MATERIAL AND METHODS We screened consecutive children admitted for community-acquired pneumonia at the Emergency Department of Guangzhou Women's and Children's Medical Center between 2017 and 2019. Adenovirus infection was confirmed through rapid respiratory virus assay, RT-PCR assay from respiratory secretions, or serum IgM antibodies. According to Chinese guidelines, patients with pneumonia were classified into severe and mild groups. We assessed risk factors for severe adenovirus pneumonia by comparing clinical features and laboratory indicators, then included differing factors between the 2 groups in a logistic regression analysis. Data analysis was performed using SPSS 26.0 software. RESULTS Our study included 173 children diagnosed with adenovirus pneumonia (117 severe, 56 mild). The median age was 40 months, with 64 male patients. Univariate analysis and binary logistic regression analysis revealed that pleural effusion (13.449 [1.226-147.510], p=0.033), electrolyte disturbances (15.149 [2.724-84.246], p=0.002), oxygen therapy (258.219 [20.684-3223.548], p<0.001), bronchoscopy (26.781 [6.088-117.805], p<0.001), and steroid administration (6.584 [1.497-28.953], p=0.013) were associated with the severity of adenovirus pneumonia. CONCLUSIONS This single-center retrospective study identified pleural effusion, the need for bronchoscopy, oxygen therapy, and steroid treatment, along with impaired serum electrolytes, as factors associated with severe adenovirus pneumonia in children.

MDSCs in sepsis-induced immunosuppression and its potential therapeutic targets

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. In sepsis, a complicated immune response is initiated, which varies over time with sustained excessive inflammation and immunosuppression. Identifying a promising way to orchestrate sepsis-induced immunosuppression is a challenge. Myeloid-derived suppressor cells (MDSCs) comprise pathologically activated neutrophils and monocytes with potent immunosuppressive activity. They play an important part in inhibiting innate and adaptive immune responses, and have emerged as part of the immune response in sepsis. MDSCs numbers are persistently high in sepsis patients, and associated with nosocomial infections and other adverse clinical outcomes. However, their characteristics and functional mechanisms during sepsis have not been addressed fully. Our review sheds light on the features and suppressive mechanism of MDSCs. We also review the potential applications of MDSCs as biomarkers and targets for clinical treatment of sepsis.

Pathobiology, Severity, and Risk Stratification of Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference

OBJECTIVES

To review the literature for studies published in children on the pathobiology, severity, and risk stratification of pediatric acute respiratory distress syndrome (PARDS) with the intent of guiding current medical practice and identifying important areas for future research related to severity and risk stratification.

DATA SOURCES

Electronic searches of PubMed and Embase were conducted from 2013 to March 2022 by using a combination of medical subject heading terms and text words to capture the pathobiology, severity, and comorbidities of PARDS.

STUDY SELECTION

We included studies of critically ill patients with PARDS that related to the severity and risk stratification of PARDS using characteristics other than the oxygenation defect. Studies using animal models, adult only, and studies with 10 or fewer children were excluded from our review.

DATA EXTRACTION

Title/abstract review, full-text review, and data extraction using a standardized data collection form.

DATA SYNTHESIS

The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize relevant evidence and develop recommendations for clinical practice. There were 192 studies identified for full-text extraction to address the relevant Patient/Intervention/Comparator/Outcome questions. One clinical recommendation was generated related to the use of dead space fraction for risk stratification. In addition, six research statements were generated about the impact of age on acute respiratory distress syndrome pathobiology and outcomes, addressing PARDS heterogeneity using biomarkers to identify subphenotypes and endotypes, and use of standardized ventilator, physiologic, and nonpulmonary organ failure measurements for future research.

CONCLUSIONS

Based on an extensive literature review, we propose clinical management and research recommendations related to characterization and risk stratification of PARDS severity.

Impact of extracorporeal membrane oxygenation in immunocompetent children with severe adenovirus pneumonia

BACKGROUND

Severe adenovirus (Adv.) pneumonia can cause significant mortality in young children. There has been no worldwide consensus on the impact of extracorporeal membrane oxygenation (ECMO) in immunocompetent children with severe Adv. pneumonia. This study aimed to assess the impact of ECMO in immunocompetent children with severe Adv. pneumonia.

METHODS

This study evaluated the medical records of 168 hospitalized children with severe Adv. pneumonia at the Guangzhou Women and Children's Medical Center between 2019 and 2020.Nineteen patients in the ECMO group and 149 patients in the non-ECMO group were enrolled.

RESULTS

Between these two groups, there were no differences in host factors such as sex, age (all P > 0.05). Significant differences were observed in shortness of breath/increased work of breathing; cyanosis; seizures; tachycardia; the partial pressure of oxygen in arterial blood (PO₂); the ratio of PaO₂ to the fraction concentration of oxygen in inspired air (FiO₂; P/F); white blood cell, lymphocyte, monocytes, lactate dehydrogenase (LDH), serum albumin, and procalcitonin levels; and, pulmonary consolidation (all P < 0.05). There were significant differences in the parameters of mechanical ventilation (MV) therapy and complications such as respiratory failure, acute respiratory distress syndrome, septic shock, length of hospitalization, and death (all P < 0.05). The maximum axillary temperatures, respiratory rates, heart rates and LDH levels after receiving ECMO were significantly lower than those before ECMO (all P < 0.05). Additionally, SPO₂, PO₂, and P/F were significantly higher than those before ECMO (all P < 0.05). In MV therapy, FiO₂, PIP, and PEEP were significantly lower than those before ECMO (all P < 0.05).

CONCLUSIONS

In our study, the clinical conditions of the patients in the ECMO group were much more severe than those in the non-ECMO group. Our study showed that ECMO might be beneficial for the patients with severe Adv. pneumonia.

Analysis of mortality risk factors in children with severe adenovirus pneumonia: A single-center retrospective study

BACKGROUND

Human adenovirus (HAdV) is one of the most common viruses causing respiratory infections among young children. Most adenovirus infections are mild and self-limited; however, these infections may occasionally cause severe pneumonia and even death. The mortality risk factors for severe adenovirus pneumonia are not completely clear. This study aimed to evaluate the mortality risk factors in children with severe adenovirus pneumonia.

METHODS

A retrospective study of children with severe adenovirus pneumonia hospitalized in Guangzhou Women and Children's Hospital between July 2018 and January 2020 was performed. Binary logistic regression analysis was used to identify independent mortality risk factors for severe adenovirus pneumonia after univariate analysis.

RESULTS

Our study included 189 patients (123 males and 66 females). Among them, 13 patients did not survive with a mortality of 6.88%. In multivariate analysis, the independent mortality risk factors in children with severe adenovirus pneumonia were age less than 1 year (OR = 18.513, 95% CI: 2.157-158.883, p = 0.008), hypoxia (OR = 62.335, 95% CI: 2.385-1629.433, p = 0.013), and thrombocytopenia (platelet <100∗10ˆ9/L) (OR = 13.324, 95% CI: 1.232-144.075, p = 0.033).

CONCLUSIONS

In children with severe adenovirus pneumonia who are younger than one year old, hypoxia and platelet counts less than 100∗10ˆ9/L represent mortality risk factors.

Transfusion Ratios and Deficits in Injured Children With Life-Threatening Bleeding

OBJECTIVES

To assess the impact of plasma and platelet ratios and deficits in injured children with life-threatening bleeding.

DESIGN

Secondary analysis of the MAssive Transfusion epidemiology and outcomes In Children study dataset, a prospective observational study of children with life-threatening bleeding events.

SETTING

Twenty-four childrens hospitals in the United States, Canada, and Italy.

PATIENTS

Injured children 0-17 years old who received greater than 40 mL/kg total blood products over 6 hours or were transfused under activation of massive transfusion protocol.

INTERVENTION/EXPOSURE

Weight-adjusted blood product volumes received during the bleeding event were recorded. Plasma:RBC ratio (plasma/RBC weight-adjusted volume in mL/kg) and platelet:RBC ratio (platelet/RBC weight-adjusted volume in mL/kg) were analyzed. Plasma deficit was calculated as RBC mL/kg - plasma mL/kg; platelet deficit was calculated as RBC mL/kg - platelet mL/kg.

MEASUREMENTS AND MAIN RESULTS

Of 191 patients analyzed, median (interquartile range) age was 10 years (5-15 yr), 61% were male, 61% blunt mechanism, and median (interquartile range) Injury Severity Score was 29 (24-38). After adjusting for Pediatric Risk of Mortality score, cardiac arrest, use of vasoactive medications, and blunt mechanism, a high plasma:RBC ratio (> 1:2) was associated with improved 6-hour survival compared with a low plasma:RBC ratio (odds ratio [95% CI] = 0.12 [0.03-0.52]; p = 0.004). Platelet:RBC ratio was not associated with survival. After adjusting for age, Pediatric Risk of Mortality score, cardiac arrest, and mechanism of injury, 6-hour and 24-hour mortality were increased in children with greater plasma deficits (10% and 20% increased odds of mortality for every 10 mL/kg plasma deficit at 6 hr [p = 0.04] and 24 hr [p = 0.01], respectively); 24-hour mortality was increased in children with greater platelet deficits (10% increased odds of 24-hr mortality for every 10 mL/kg platelet deficit [p = 0.02)]).

CONCLUSIONS

In injured children, balanced resuscitation may improve early survival according to this hypothesis generating study. Multicenter clinical trials are needed to assess whether clinicians should target ratios and deficits as optimal pediatric hemostatic resuscitation practice.

Extracorporeal membrane oxygenation for paediatric refractory hypoxic respiratory failure caused by adenovirus in Shanghai: a case series

Background

To assess the outcome of extracorporeal membrane oxygenation (ECMO) for severe adenovirus (Adv) pneumonia with refractory hypoxic respiratory failure (RHRF) in paediatric patients.

Methods

A retrospective observational study was performed in a tertiary paediatric intensive care unit (PICU) in China. Patients with RHRF caused by Adv pneumonia who received ECMO support after mechanical ventilation failed to achieve adequate oxygenation between 2017 and 2020 were included. The outcome variables were the in-hospital survival rate and the effects of ECMO on the survival rate.

Results

In total, 18 children with RHRF received ECMO. The median age was 19 (9.5, 39.8) months, and the median ECMO duration was 196 (152, 309) h. The in-hospital survival rate was 72.2% (13/18). Thirteen patients (72.2%) required continuous renal replacement therapy (CRRT) due to fluid imbalance or acute kidney injury (AKI). At ECMO initiation, compared with survivors, nonsurvivors had a lower PaO₂/FiO₂ ratio [49 (34.5, 62) vs. 63 (56, 71); p = 0.04], higher oxygen index (OI) [41 (34.5, 62) vs. 30 (26.5, 35); p = 0.03], higher vasoactive inotropic score (VIS) [30 (16.3, 80) vs. 100 (60, 142.5); p = 0.04], longer duration from mechanical ventilation to ECMO support [8 (4, 14) vs. 4 (3, 5.5) h, p=0.02], and longer time from confirmed RHRF to ECMO initiation [9 (4.8, 13) vs. 5 (1.3, 5.5) h; p = 0.004]. Patients with PaO₂/FiO₂ <61 mmHg or an OI >43 and hypoxic respiratory failure for more than 9 days before the initiation of ECMO had worse outcomes.

Conclusions

ECMO seemed to be effective, as severe paediatric Adv pneumonia patients with RHRF had a cumulative survival rate of 72.2% in our study. Our study provides insight into ECMO rescue in children with severe Adv pneumonia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03197-2.

The Clinical Risk Factors of Adenovirus Pneumonia in Children Based on the Logistic Regression Model: Correlation with Lactate Dehydrogenase

METHODS

Children with bacterial pneumonia (41 cases) and adenovirus pneumonia (179 cases) hospitalized in Tianjin Children's Hospital from January to October 2020 were selected. The differences in baseline and clinical characteristics between children with two pneumonias, respectively, were compared via the chi-square test and Wilcox test. The Least Absolute Shrinkage and Selection Operator (LASSO) model was applied to screen the pneumonia type-related characteristics. Patients were randomly divided into the training set (n = 154) and test set (n = 66). The logistic model was constructed using the screened characteristics in the training set to predict whether the cases are bacterial pneumonia or adenovirus pneumonia. Finally, the model was validated by receiver operating characteristic (ROC) curve and area under curve (AUC) in the test set.

RESULTS

The age (p < 0.001), hospital stay (p < 0.001), tonsil condition (p < 0.001), interleukin-6 (IL-6; p=0.033), and lactate dehydrogenase (LDH; p < 0.001) between children with bacterial pneumonia and adenovirus pneumonia were significantly different. Sex, tonsil condition, age, hospital stay, r-glutamyltransferase (r-GT), and LDH levels were the factors associated with the types of pneumonia. Compared with bacterial pneumonia, children with adenovirus pneumonia were younger (OR = 0.207, 95% CI: 0.041-0.475), with longer hospital stay (OR = 7.974, 95% CI: 2.626-74.354) and higher LDH expression level (OR = 1.025, 95% CI: 1.006-1.060). 92.4% types of pneumonia were correctly predicted, and the AUC value of the model was 0.981.

CONCLUSION

The LDH level was the associated factor to predict the types of pneumonia. Adenovirus pneumonia was associated with earlier age and longer hospital stay than bacterial pneumonia. The established model can well predict the types of pneumonia in children and provide clinical basis for guiding the individualized treatment of children.

The Epidemiology, Molecular, and Clinical of Human Adenoviruses in Children Hospitalized With Acute Respiratory Infections

Introduction

Human adenovirus (HAdV) is a common pathogen in children with acute respiratory infections (ARIs). The aim was to describe the epidemiology, molecular, and clinical characteristics of HAdV among children hospitalized with ARIs in Wenzhou in southeastern China.

Methodology

From January 2018 to December 2019, nasopharyngeal swab or sputum specimens were prospectively collected from hospitalized children with ARIs. HAdV was detected using direct immunofluorescence. We used a multiplex PCR assay combined with capillary electrophoresis targeting the hexon gene’s hypervariable region to identify HAdV types 1, 2, 3, 4, 5, 7, 14, 21, 37, 40, 41, and 55. We analyzed the epidemiological, molecular, and clinical data according to the HAdV type.

Results

HAdVs were detected in 1,059 (3.5%) of the total of 30,543 children tested. A total of 947 cases with monotype HAdV identified by the PCR assay were included in the analysis. HAdV-3 (415/947, 43.8%), HAdV-7 (318/947, 33.6%), HAdV-2 (108/947, 11.4%), and HAdV-1 (70/947, 7.4%) were the predominant types. Of the 550 (58.1%) cases detected from December 2018 to August 2019, HAdV-3, and HAdV-7 were the main types. The main diagnoses included 358 cases of pneumonia, 232 cases of tonsillitis, 198 cases of bronchitis, and 159 cases of upper respiratory tract infection (URTI). Among children with pneumonia the main types were HAdV-7 (51.1%), HAdV-3 (36.9%), and HAdV-1 (2.2%). Among children with bronchitis, the main types were HAdV-3 (48.0%), HAdV-7 (28.3%), and HAdV-2 (10.6%). Among children with URTIs, the main types were HAdV-3 (49.7%), HAdV-7 (22.6%), and HAdV-2 (13.2%). Among children with tonsillitis, the main types were HAdV-3 (47.4%), HAdV-2 (22.4%), and HAdV-7 (18.5%). In total, 101 (55.2%) patients required supplemental oxygen, 15 (8.2%) required critical care, and 1 child (0.5%) with HAdV-7 pneumonia died.

Conclusion

HAdV-3 -7, -2, and -1 were the predominant types identified in hospitalized children with ARIs in Wenzhou. From December 2018 to August 2019, there were outbreaks of HAdV-3 and -7. There were significant differences in HAdV types among children with pneumonia, tonsillitis, bronchitis, and URTI. HAdV-7 can cause more severe pneumonia in children than HAdV-3.