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Adverse Occurrence type:
Kidneys, lungs, heart, liver and pancreas from a common donor were transplanted to 5 recipients. Three of them developed cocciodioidomycosis.
Time to detection:
Two of the recipients (kidneys) developed disseminated infection and became symptomatic on post-transplant day (PTD) +26 to +29. The kidney transplant recipient was diagnosed with pulmonary coccidioidomycosis on PTD +42. The simultaneous pancreas and kidney transplant recipient was diagnosed on PTD +36. The bilateral lung recipient was diagnosed with pleural effusion on day +53.
Alerting signals, symptoms, evidence of occurrence:
Recipients presented with fever, persistent headache, diarrhoea, dyspnea and cough. Initial chest xRay did not reveal abnormalities but CT demonstrated pulmonary nodules. Coccidioides spp was isolated from blood cultures and brocho-alveolar lavage but full, confirmed organism identification was not obtained and isolates were not available for retrospective analysis. The kidney recipient responded to prolonged Amphotericin B treatment but the Kidney-pancreas recipient died on PTD+36 despite antifungal treatment. Both EIA and complement fixation serology were used. The liver recipient received fluconazole as part of routine post-transplant prophylaxis and did not show any evidence of coccidioides infection. The recipient of lungs received voriconazole due to positive donor BAL for Aspergillus, at the time of transplant; this recipient developed a very low CF Ab titre with no symptoms of coccidioidomycosis.
Demonstration of imputability or root cause:
Donor was born in Jamaica (a non-endemic area) and, once recipients had been diagnosed with coccidioidomycosis, donor blood tested positive by EIA. Three of the five recipients (kidney, combined pancreas kidney, bilateral lung) were diagnosed by isolation of coccidioides from different clinical samples (blood and BAL). The other two (liver, heart) remained asymptomatic and were screened with serology, with a negative result; the lung recipient had travelled to Colorado.
Suggest new keywords:
coccidioidomycosis, coccidioides immitis, solid organ transplantation
1) Dierberg KL1, Marr KA, Subramanian A, Nace H, Desai N, Locke JE, Zhang S, Diaz J, Chamberlain C, Neofytos D. Donor-derived organ transplant transmission of coccidioidomycosis. Transpl Infect Dis. 2012 Jun;14(3):300-4 2) Roy M, Park BJ, Chiller TM. Donor-derived fungal infections in travel patients. Curr Fungal Infect Rep 2010;4:219-28.
I have changed the status from rejection to ready to upload because I consider that we do not have to merge cases as each one has is own characteristics. People looking for information will reach it using the search tool (Oscar) Record edited Oct 2017 (2nd editor, Ines).
Expert comments for publication:
This cluster highlights several important points: the difficulties and importance of obtaining a good travel history and associated risks; need for timely and full identification of isolates; prompt communication between centers to allow apropriate management of recipients .