From: Reuters
Published April 3, 2008 07:43 PM

TB spread from donor to recipient needs fast action

NEW YORK (Reuters Health) - The transmission of tuberculosis from a donor organ to a transplant recipient may result in spread of the bacteria outside of the lungs, leading to a wide-spread infection, which may result in unusual symptoms that can make diagnosis difficult. Early recognition of the infection is "critical, as demonstrated by three cases described in the Morbidity and Mortality Weekly Report.

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 in the 6 months before his death in early June 2007 for 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 the fluid in his spine grew Mycobacterium tuberculosis, the bacterium that causes TB.

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

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A 50-year-old recipient of one of the kidneys developed pancytopenia, a depletion of the body's primary blood cells - red blood cells, white blood cells and platelets. The primary functions of these cells are to transport oxygen, fight infection and clot the blood, respectively.

Other symptoms included fever and, 6 weeks after the transplantation, the patient developed a sepsis-like syndrome, a serious, often fatal immune response, 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.

Examination of the genes in the TB strains isolated from the donor and recipient were identical, 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 if the patient has persistent fever, pneumonia, meningitis, septic arthritis, kidney complications, 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:

-- Testing for mycobacterial and X-ray assessment when risk factors are identified;

-- Obtain a specimen from the donor for routine bacterial testing, including TB;

--Save blood and tissue samples from the donor that are suitable for laboratory evaluation.

"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."

SOURCE: Morbidity and Mortality Weekly Report for April 4, 2008.

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