NON-VIRAL INFECTIONS IN TRANSPLANTATION

K.E. Kokko¹, E. Farnon², F.K. Butt³, A.M. Hawxby³, J. Fratkin⁴, A.H. Seawright³, W. Shieh², A. Dasilva², G. Visvesvara², S. Zaki², M. Kuehnert², O.B.O. The balamuthia transplant investigation team^5
1Medicine, University of Mississippi Medical Center, Jackson/MS/UNITED STATES OF AMERICA, ², Centers for Disease Control and Prevention, Atlanta/UNITED STATES OF AMERICA, ³Surgery, University of Mississippi Medical Center, Jackson/MS/UNITED STATES OF AMERICA, ⁴Pathology, University of Mississippi Medical Center, Jackson/UNITED STATES OF AMERICA, ⁵, University of Mississippi Med Ctr and the CDC, Jackson & Atlanta/UNITED STATES OF AMERICA

Body: Introduction: Balamuthia mandrillaris, a free-living amoeba causing granulomatous amoebic encephalitis (GAE), has approximately 150 cases described worldwide, with few known survivors. We report the first identified transmission of B. mandrillaris through solid organ transplantation. Methods: Medical records and histopathology was reviewed; specimens were tested for B. mandrillaris at the Centers for Disease Control and Prevention (CDC) by immunohistochemistry (IHC), indirect immunofluorescent assay (IFA) and real-time PCR. Results: In November 2009, transplantation of two kidneys, a heart and a liver was performed at three different centers in the United States from a donor with a presumptive diagnosis of autoimmune encephalitis. The two kidney recipients received anti-lymphocytic antibody as induction therapy and three weeks later, developed abrupt onset of fever, altered mental status, and seizures, requiring intubation. Brain MRIs revealed multiple ring-enhancing lesions. CSF examination initially demonstrated protein elevation and subsequently, neutrophilic pleiocytosis. Histopathology of donor brain tissue revealed amoebae by IHC and B. mandrillaris by IFA and real-time PCR. These results were confirmed by brain biopsy in one of the kidney recipients and both recipients had CSF samples that were positive for B. mandrillaris by PCR. One patient is showing signs of neurologic recovery, with CSF samples now negative for B. mandrillaris by PCR, while the other has died despite immunosuppression withdrawal and aggressive multi-drug therapy for GAE, including miltefosine. Although the liver and heart recipients are asymptomatic to date, they have been treated prophylactically for B. mandrillaris. Conclusion: These are the first reported cases of B. mandrillaris transmission through solid organ transplantation. Donors with encephalitis of uncertain etiology may transmit unusual infections to recipients with devastating consequences. The presentation of GAE in transplant recipients may differ from other infected individuals. Clinicians should have a low threshold to suspect donor-derived infections in transplant patients receiving organs from donors with encephalitis and promptly report, test and treat all suspected cases.

Disclosure: All authors have declared no conflicts of interest.