More cases of Balamuthia encephalitis transmitted via organ transplantation

Late last year, we blogged about the transmission of Balamuthia mandrillaris from an organ donor with an undiagnosed encephalitis in Mississippi to 2 organ recipients (liver and kidney-pancreas) who subsequently developed encephalitis. One recipient died of encephalitis and the other survived with neurologic sequelae. These cases are described in the most recent MMWR. Then there was the report in Clinical Infectious Diseases of transmission of rabies to 2 organ recipients who died. Again the donor had an undiagnosed encephalitis. Seven other cases of transplant-associated rabies had been previously described. Now the Arizona Star and MMWR are reporting another cluster of two Balamuthia encephalitis cases who received organs from a 27-year old man who died of what was thought to be a stroke (no details on brain imaging are included in either report).

Several months ago, I argued that there should be an immediate ban on transplanting organs from donors with undiagnosed encephalitides (and I would now add other neurologic diseases without a confirmed diagnosis) in cases where transplantation is not immediately life-saving (e.g., cornea, kidney, intestine, pancreas, musculoskeletal grafts). And where transplantation is potentially immediately life-saving (e.g., heart, liver), full disclosure of the donor's diagnosis and its implications should be made available as part of the informed consent process. I was surprised that CDC did not make this recommendation earlier, and even more so after additional cases have been reported.

Transplantation associated rabies

There's an interesting and disturbing report in Clinical Infectious Diseases that describes the transplantation of organs to six recipients from a donor with undiagnosed rabies. The donor was a 26-year old woman who presented with an encephalitis-like picture and negative testing for the usual causes of encephalitis. Approximately six weeks post-transplant, it was noted that three of the recipients began to exhibit symptoms similar to the donor. Review of archived brain samples from the donor revealed characteristic histopathologic and electron microscopy findings of rabies. Further investigation about the donor revealed that she had traveled to India where she sustained a dog bite. All of the recipients were treated with rabies immune globulin and vaccine. The two cornea recipients underwent explantation of the corneas, did not become ill, never exhibited any virologic evidence of infection, and survived. The liver recipient also remained healthy and had no virologic evidence of infection; however, it is important to note that he had received rabies vaccine 20 years earlier. The other three recipients (lung, kidney, kidney/pancreas) all died of rabies despite aggressive treatment with the Milwaukee protocol.

A few months ago we blogged about two cases of Balamuthia encephalitis transmitted by an organ donor in Mississippi. Since then, at least one of the infected recipients has died. The common theme here is that both the rabies and Balamuthia infected donors died with undiagnosed encephalitides. While I agree with Eli that a complete analysis of the problem is warranted, I don't agree that actions should wait for the conclusions of such analysis. Interim actions should be taken. It seems to me that at a minimum there should be an immediate ban on transplanting organs from donors with undiagnosed encephalitides in cases where transplantation is not immediately life-saving (e.g., cornea, kidney, intestine, pancreas, musculoskeletal grafts). And where transplantation is potentially immediately life-saving (e.g., heart, liver), full disclosure of the donor's diagnosis and its implications should be made available as part of the informed consent process. I suspect that donors with undiagnosed encephalitides comprise a small fraction of the donor pool anyway, though I appreciate the scarcity of organs for transplantation.

Primum non nocere!

Media and the Public Health Response

Recently, I have become interested in how the media influences the public health response and watched with fascination as the H1N1 saga unfolded. As Mike pointed out earlier, the New York Times has written about the recent transplant-related transmission of Balamuthia mandrillaris and whether this one-off event should change overall transplantation guidelines nationwide. I hope the NY Times' assertion that patients with undiagnosed neurological conditions should be barred from donating organs is analyzed and public health officials don't make a knee-jerk decision based on immediate/transitory media attention or political pressure.

Decisions like these are quite complicated and proper analysis can turn-up unexpected findings. Two years ago, I co-authored an article in the American Journal of Transplantation with Eugene Schweizer and others at the University of Maryland that analyzed what would happen if kidneys were transplanted from donors considered high-risk for HIV or Hepatitis C, yet had tested negative. The current practice is to discard these valuable organs. Our most surprising finding was that the total number of viral infections in recipients was actually LOWER with the policy of transplanting these organs. The reason? It turns out that discarding kidneys from high-risk donors led to more time on hemodialysis which resulted in a higher Hepatitis C incidence in recipients. The transplant policy also resulted in higher quality of life and lower cost of care.

Now, the NY Times article is quite balanced, but this won't necessarily stop public health officials from making decisions before a proper analysis is completed. Let's hope cooler heads prevail before a "national policy on whether to bar people with poorly defined neurological disorders as donors" is decided by officials and not scientists. The one thing that is certain is that there is nothing harder to define than a neurological condition.

More on infections transmitted by donor organs

Over a week ago I noted the two cases of Balamuthia mandrillaris infections transmitted to two organ transplant recipients from a donor in Mississippi. Until today, the media attention had only been local. This morning's New York Times is covering this story and raises the question of whether patients with undiagnosed neurologic conditions, such as the donor in these cases, are acceptable donors or whether they should be excluded from the transplantation process.

In the news

Just about every day, I take a look at what's appearing in the mainstream media so that readers of this blog can link to the latest, hottest happenings in the world of infectious diseases and infection prevention. Today's foray yielded a treasure trove:

• First it was Christmas decorations. Then aquariums. Now British hospitals are banning flowers on wards in the name of infection prevention. I suggest they next ban food, water, and air, since none of those are sterile either.
• Two of four patients who received organs from a patient who died at the University of Mississippi Medical Center last month have been diagnosed with infections due to Balamuthia mandrillaris, a free-living amoeba that can cause encephalitis. Both patients are critically ill. Infections with these organisms are rare, and these are the first to be transmitted via transplanted organs.
• Dr. Sidney Wolfe, the well known patient advocate at Public Citizen, has added Tamiflu to his list of worst pills. The title of the press release says it all--"Tamiflu? More like Scamiflu."
• In Scotland, three injection drug users have developed cutaneous anthrax, one of whom has died of the infection.
• Lastly, if you are planning on having plastic surgery anytime soon in Connecticut, be careful! A plastic surgeon there has been cited because inspectors found mouse poop on her surgical instruments. I didn't make this up, really! See the link here.