Rabies Transmitted by Organ Transplant

In March 2013, an army veteran in Maryland, USA, died of a rabies infection usually associated with raccoons. With no known exposure to animals, suspicion fell on a kidney transplant carried out almost 18 months previously, and stored samples were able to confirm rabies infection in the donor. This unusual situation has happened only twice before in the USA, in 1997 as the result of a corneal transplant and in 2004, when 3 recipients of organs died of rabies (and a fourth died too soon after the transplant for rabies to be suspected.

In the most recent case, the organ donor was a 20-year-old Air Force recruit. His symptoms were thought to be caused by a food-borne toxin, ciguatera, carried by saltwater fish, and the cause of death was recorded as encephalitis of unknown origin. Tests for HIV, hepatitis and some other diseases are carried out routinely on potential organ donors, but this donor was not tested for rabies, a rare cause of death not routinely considered. A rabies test after a death can take four hours once the sample reaches the lab, but kidneys remain viable for less than 24 hours after the donor dies, and other organs less than 6 hours. Doctors must weight the risk of possible infection with the risk of the patient not receiving the transplant.

Organs from the same donor went to recipients in Florida, Georgia and Illinois as well as the recipient in Maryland who died. Immediate rabies post exposure prophylaxis (PEP) was administered to these other recipients (who had shown no symptoms of rabies), and after 5 doses of vaccine, these people are now considered out of danger. A further 36 people who had close contact with the recipients or donor also have been urged to seek PEP.

The Centers for Disease Control and Prevention is looking into why this case was so different from the situation in 2004, when all recipients of donated organs died of a bat-associated rabies infection within seven weeks. The virus strain, the amount of virus present in the donated organs, the recipient’s genetic predisposition or treatments may have influenced the outcome.

The case raises questions about the use of organs from people who die of poorly defined disorders. Updated guidelines on the use of organs have been developed since, and urge caution when considering donors with encephalitis, and "extreme caution" when the encephalitis appears to be from a virus.  However, these guidelines were not in place at the time of the transplants in 2011.

Summarised by Louise Taylor from reports in the New York Times, NBC news, Huffington Post, USA Today, and Washington Post.