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Record number: 
Adverse Occurrence type: 
Estimated frequency: 
Review of cases reported to the Disease transmission Advisory Committee (DTAC, USA) between 2005 to 2012, revealed 6 donors with evidence of coccidiodiomycosis infection based on serologies, culture or histopathology transplanted organs into 21 recipients. Of the 21 recipients, 9 (43%) showed evidence of coccidiodiomycosis infection with 4 deaths. This paper also described previous literature (1950 to 2013) showing transmission of cocciodiodiomycosis from 7 donors into 18 recipients with a 61% (n=11) incidence of infection and 7/18 death (no reference provided in the paper)
Time to detection: 
The median time to detection of coccidiodiomycosis infection post-transplant was 30 days in this publication. In comparison, the literature search revealed a medium time to detection of 14 days post-transplant (range 6 to 60 days)
Alerting signals, symptoms, evidence of occurrence: 
Dissemination to blood, cerebrospinal fluid (in two recipients), kidney abscess in one recipient, liver and lung nodules, with positive cultures, histopathology and serologies. 2 recipients (one kidney and one liver) with negative pre-transplant serology did not develop demonstrable infection through post-transplant serology, histopathology or culture. Serologic data reported in 4 recipients from 3 donors (with no pretransplant serologies): 1. Kidney-Liver recipient - Complement fixation of 1:64 at 3 months posttransplant 2. Kidney recipient - Complement fixation of 1:4 at 2 months posttransplant (specifically at 59 days) 3. Bilateral lung recipient - Complement fixation of 1:2 at 2 months (specifically 53 days) 4. Kidney recipient - Complement fixation of 1:64 at 3 months posttransplant
Demonstration of imputability or root cause: 
Imputability for 6 of the 7 donors - one donor had a positive hilar lymph node for cocci, and the recipient received fluconazole prophylaxis, becoming "ill" at day 6 post-transplant (no details with regard to workup or source of illness) but survived. Unclear if there was a true transmission of cocci in this case. The other 6 of the 7 donors transmitted coccidiodiomycosis based on the objective criteria of culture, histopathology and/or positive serologies with a mortality rate of 28.5% at 6 months. Of note, 11 patients received fluconazole prophylaxis, 2 of whom had no evidence of disease post-transplant, and all of whom survived despite developing acute cocci infection. 1 donor transmitted to both kidney recipients (one of whom died) and liver recipient while the heart recipient survived with no mention of disease, all of whom did not receive fungal prophylaxis. Therefore, imputability/root cause demonstrated in 6/7 donors to multiple recipients, negating the possibility of reactivation of cocci in these recipients.
Imputability grade: 
3 Definite/Certain/Proven
Suggest new keywords: 
preemptive antifungal
liver granulomas
complement-fixation test
amphotericin B
kidney transplant
heart transplant
liver transplant
lung transplant
Suggest references: 
Coccidioidomycosis Transmission Through Organ Transplantation: A Report of the OPTN Ad Hoc Disease Transmission Advisory Committee. Kusne S et al. Am J Transplant. 2016 Jul 4
Questions- Criteria for testing donors (depending on local epidemiology and risk-assessment) . Availability of validated tests that can be used in the context of deceased organ donation; assume post-donation result acceptable, with early intervention as required
Expert comments for publication: 
Coccidiodiomycosis is endemic to the southwestern part of the United States, Central and South America. Donor screening for exposure to coccidiodiomycosis should be considered according to locally assessed risk-benefit due to the high transmission rate and development of infection in organ recipients with high rates of morbidity and mortality. In this cohort of transplant recipients, early fluconazole prophylaxis prevented death in all recipients. Report of coccidiodiomycosis infection in one recipient should alert transplant physicians to initiate fluconazole prophylaxis in all recipients from the same donor. The duration of fungal prophylaxis varies in the literature, with prophylaxis ranging from 6 months to lifelong, particularly if acute infection identified (see Singh et al, American Transplant Society Guidelines).