Adverse Occurrence type:
Multiorgan donor, TB transmission occurred only in the recipient of the double lung transplant (TB positive graft). Of the other four recipients (liver, left kidney/pancreas, right kidney and heart), three were treated with isoniazid prophylaxis without infection transmission (intervention without disease transmission, IWDT).
Time to detection:
Alerting signals, symptoms, evidence of occurrence:
MULTIORGAN DONOR: 40-year-old male from a high tuberculosis (TB) incidence country. He had been diagnosed with TB 10 years earlier. His family stated he had received adequate treatment and was asymptomatic. Cause of death: stroke, no autopsy was performed. Chest X ray normal. Biopsy PCR from apical lung lesions was reported positive for M.tuberculosis 6 days after organ retrieval. The involved transplant centers were notified. RECIPIENTS: DOUBLE LUNG: 59 -years. Gender not stated, previous tuberculin skin test (TST) negative. Because of graft TB, the patient received treatment with isoniazid, ethambutol, moxifloxacin and pyrazinamide for 18 months. Alive with functioning graft after a 14- month follow-up period. HEART: 46 years, gender not stated, TST not performed, received isoniazid prophylaxis for 12 months, no TB during a 12-month follow up period. PANCREAS & LEFT KIDNEY: 36 years, gender not stated, negative TST, received isoniazid prophylaxis for 3 months, died at 3 months due to abdominal sepsis. No TB transmission documented. RIGHT KIDNEY: TST positive, no isoniazid prophylaxis was given, no TB during a 15-month follow up period. LIVER: Negative TST, received isoniazid prophylaxis for 12 months, no TB during a 14-month follow up period.
Demonstration of imputability or root cause:
Polmunary TB confirmed by positive M. tuberculosis PCR.
Coll E, Torre-Cisneros J, Calvo R, Garrido G, Matesanz R. Incidence of tuberculosis in deceased-organ donors and transmission risk to recipients in Spain. Transplantation. 2013 Jul 27;96(2):205-10.