Clinical

Rapid action needed in suspected TB transmission from donor to organ recipient

Last Updated: 2008-04-03 13:28:24 -0400 (Reuters Health)

NEW YORK (Reuters Health) - Donor-transmitted tuberculosis in transplant recipients may cause extrapulmonary and disseminated infection, leading to atypical signs that can make diagnosis difficult. Nonetheless, early recognition is critical, as demonstrated by three cases described in the Morbidity and Mortality Weekly Report for April 4.

Dr. V. Kohli, at Integris Baptist Medical Center in Oklahoma City, and colleagues report that a 46-year-old organ donor had been hospitalized three times during the 6 months before his death in early June, 2007, for treatment of presumed aspiration pneumonia.

He had a history of alcoholism, homeless, and incarceration, but tuberculin skin tests were negative. Three weeks after his death, a culture from cerebrospinal fluid grew Mycobacterium tuberculosis.

The three recipients of the donor's kidneys and liver were not notified until late July, when they were started on anti-TB therapy.

A 50-year-old recipient of one of the kidneys developed pancytopenia, fever and a sepsis-like syndrome 6 weeks posttransplantation, leading to her death 3 weeks later.

A 23-year-old woman who received the other kidney developed fever, severe headache and pancytopenia 7 weeks later. She fully recovered after starting anti-TB medications.

The liver recipient, a 59-year-old man, never developed TB.

Genotypes of the donor and recipient TB isolates were identical, Dr. Kohli's group reports.

They write: "Investigations of potential donor-transmitted TB requires rapid communication among physicians, transplant centers, and public health authorities."

According to the authors of a related editorial note, TB should be considered when an unusual constellation of symptoms develops within the first few weeks after transplantation. Specifically, "TB should be considered in the differential diagnosis of persistent fever, pneumonia, meningitis, septic arthritis, pyelonephritis, septicemia, graft rejection, or bone marrow suppression."

The editorialists recommend that organ procurement organizations "obtain donor history of symptoms consistent with active TB, past diagnosis of TB infection (active or latent), homelessness, excess alcohol or injection-drug use, incarceration, recent exposure to persons with active TB, or travel to areas where TB is endemic."

Other recommendations include:

--Further mycobacterial testing and radiologic assessment when risk factors are identified.

--Clinical specimens obtained from donors for routine bacterial testing should also be tested for M. tuberculosis.

--Samples of donor tissues and serum suitable for laboratory evaluation should be saved.

--"Organ procurement organizations also should follow up on results of all tests pending at the time of organ donation and notify transplant centers immediately of any results that might have implications for recipients."

Mor Mortal Wkly Rep CDC Surveill Summ 2008;57:333-336.