Mycobacterium tuberculosis

Record number: 
Adverse Occurrence type: 
MPHO Type: 
Time to detection: 
21 days
Alerting signals, symptoms, evidence of occurrence: 
DONOR: 31-year-old male with sepsis and pneumonia. He died from intracerebral bleeding. BAL was Ziehl Nielsen negative and M.tuberculosis (MTB) PCR negative, but BAL culture turned positive for MTB 1 day after organ procurement. RECIPIENT: 62 year-old male with dilated cardiomyopathy. When the donor BAL turned positive, one day after transplantation, blood cultures (BACTEC Myco/F Lytic) and tracheal aspirates for mycobacterial cultures were obtained from the recipient, and he started treatment with prophylactic isoniazid 300 mg/day; 3 weeks later recipient's blood cultures turned positive for MTB. Respiratory samples remained negative. He started antiTB treatment with streptomycin, ethambutol and levofloxacin. The recipient died 3 months after heart transplantation (massive intracerebral bleeding). He never showed signs of active tuberculosis infection; post-mortem histological examination (brain, lung, heart,kidney, pancreas) and MTB PCR of these tissues were all negative for MTB.
Demonstration of imputability or root cause: 
Same M. tuberculosis strain in donor and recipient (according to molecular genotyping).
Imputability grade: 
3 Definite/Certain/Proven
Suggest references: 
Weile J, Eickmeyer H, Dreier J, Liebke M, Fuchs U, Wittke JW, Richter E,Gummert J, Knabbe C, Schulz U. First case of Mycobacterium tuberculosis transmission by heart transplantation from donor to recipient. Int J Med Microbiol. 2013 Dec;303(8):449-51.