Organ Transplantations and Rabies Transmission: Table 1

Abstract

our Americans and three Germans recently died of rabies after organ transplantation from two donors who experienced animal bites. The clinical and pathological fi ndings of the American victims were recently described. 1 The American donor presented 4 days prior to hospital admission to an emergency room with nausea, vomiting, and diffi -culty swallowing. His drug screen was positive for cocaine and marijuana. He was subsequently admit-ted to a different hospital with fever and altered men-tal status and required intubation. His mental condition was attributed to a subarachnoid hemor-rhage caused by hypertension and drug abuse. The patient ’ s condition deteriorated rapidly over the next days, and he was declared brain dead and cleared as a tissue donor. Five recipients were transplanted with kidneys, liver, lung, and an iliac artery segment. Four of them died of rabies over the next weeks, while the patient who received the lung died of operative com-plications. An investigation by the Arkansas Depart-ment of Health determined that the 20-year-old American had recently been bitten by a bat. 2 The 26-year-old German female donor fi rst went to see a doctor because of severe headache, fever, mental changes, and aggressive behavior. A drug screen was positive for cocaine, and she was believed to have a toxic psychosis. She soon suffered a cardiac arrest and was pronounced brain dead and cleared as a tissue donor. 3 Six patients were given organs (corneas, liver, lung, kidney, and kidney-pancreas); three of them died during the following weeks. 4 – 6 The bat bite in the American case and the recent visit to a rabies-endemic country with his-tory of dog bite were not elicited or not considered important. Three German organ recipients sur-vived. One had rabies vaccination some years before and was found to have detectable rabies-neutralizing antibodies in his serum prior to liver transplanta-tion. The transplanted corneas were removed and revealed no demonstrable rabies virus. Rabies can be diffi cult to diagnose where it is a rare disease. There is also lack of awareness of early-onset rabies as a cause of obscure behavioral and neurological manifestations. A rabies-infected person might be considered as an organ donor when admitted in a brain-dead state without a complete occupational, travel, and past medical history. A street person was hit by a truck and admitted at a tertiary care hospital brain dead. No history was obtainable, and his corneas were immediately transplanted. Both recipients died of rabies (H. Wilde, unpublished). It is tragic that organ transplant rabies has not been as rare as one might suspect 7 – 11 ( Table 1). We suggest that additional cases may have remained undetected or unpublished. We reviewed the literature as well as our own experience with intravitam diagnosis of rabies in 115 patients (80 furious and 35 paralytic) and present suggestions for the prevention of such tragedies in the future. 12