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Adverse Occurrence type:
Time to detection:
Alerting signals, symptoms, evidence of occurrence:
The donor was a 52-year-old African-American homeless woman who was found disoriented on the street and brought to a southern California hospital. She had a long-standing history of mental illness and did not have fever or focal neurological signs on admission. Head CT showed hydrocephalus with prominent lateral and third ventricles, MRI showed basilar artery infarcts, CSF analysis revealed protein of 25 mg/dL, glucose of 60 mg/dL, 40 WBCs/mm3(15% PMN, 62% lymphocytes, 22% monocytes, and 1% eosinophils), and 191 RBC. Repeat CSF showed similar parameters, but with lymphocytic predominance 8 days later. Donor was retrospectively tested for Coccidioides antibody complement fixation (CF), with a titer of 1:4. During procurement of the liver, a frozen section did not show abnormalities but a subsequent review revealed non-necrotizing granuloma in the portal tracts. The heart recipient was a Hispanic patient who developed shortness of breath and fever with leucocytosis on day +21. Chest x-ray with markedly enlarged cardiac silhouette; large pericardial effusion with evidence of tamponade, with cytology positive for organisms consistent with C. immitis. Mold grew in blood culture. Died on day +27 due to disseminated coccidioidomycosis without CNS involvement. Initial serology was negative. The kidney recipient was an Afro-American patient who presented on day +13 with fever, myalgia, leucocytosis and elevated AST and ALT. Blood culture grew a mold and respiratory secretions were positive for C. immits. He developed disseminated disease without CNS involvement and died on day +18. The liver and kidney recipient was a Mexican born Los Angeles resident; he developed fever on day +14 and chest CT showed small scattered bilateral pulmonary nodules and pleural effusions. Liver biopsy revealed non-caseating granulomas and endosporulating spherules consistent with C. immitis.
Demonstration of imputability or root cause:
Donor and recipients were from an endemic area for coccidioidomycosis. Donor had positive serology for Coccidioides immitis. All recipients developed disease and had positive cultures for Coccidioides immitis with similar genotypes (see Notify record number 654 for the typing methodology used).
Suggest new keywords:
coccidioidomycosis, Coccidioides immitis, solid organ transplantation, pulmonary coccidioidomycosis, disseminated coccidioidomycosis; hydrocephalus;
1) Blodget et al. Donor-derived Coccidioides immitis fungemia in solid organ transplant recipients. Transpl Infect Dis 2012:14:305–310 2) Roy M, Park BJ, Chiller TM. Donor-derived fungal infections in transplant patients. Curr Fungal Infect Rep. 2010;4:219-28. 3) Blair JE, Mulligan DC. Coccidioidomycosis in healthy personsevaluated for liver or kidney donation. Transpl Infect Dis 2007;9 (1): 78–82.
Notify record 654 corresponds to the DNA sequence typing applied to this clinical cases. It should be merged with this one and add its pdf document to this record. In my opinion "suggest references" must apply for publications that may add information to the case whilst reference attachment must include the document commented. 2nd editor work completed Oct 2017 (Ines)
Expert comments for publication:
C. immitis, is endemic in areas of southwestern United States, northern Mexico, and parts of Central and South America, causing asymptomatic infection in 60% of cases. In endemic areas or when donors are from endemic areas, Coccidioides immitis needs to be taken in consideration, as mortality in the immunocompromised is high. The authors draw particular attention to donors presenting with clinical picture consistent with active or unrecognized coccidioidomycosis (such asaltered mental status with chronic hydrocephalusand pleiocytosis in the CSF). Asymptomatic, seropositive donors have donated organs with no harm to recipients who received antifungal prophylaxis (see reference Blair et al).