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Adverse Occurrence type:
Transmission of coccidiodiomycosis from infected donors to recipients has been calculated as 43% in one paper (Kusne et al. Am J Transplant. 2016 Dec;16(12):3562-3567). In this series, 2 out of 6 recipients from a common donor seem to have become infected.
Time to detection:
4 months in the right liver lobe recipient and in the lung recipient
Alerting signals, symptoms, evidence of occurrence:
A 6 year old recipient of left liver lobe received a 3 week course of IV fluconazole from post transplant day +7 due to positive mycology culture in donor lung bronchoalveolar lavage ( BAL); this was followed with oral amphotericin B for 3 months. She went on to develop fever, abdominal pain and vomiting 4 months post-transplant and required surgical exploration. A 5 cm pseudotumor mass in the terminal portion of the ileum was found, with histology significant for spherules consistent with coccidiodiomycosis; molecular analysis confirmed Coccidioides spp. Serology, tissue culture and blood culture remained negative. The patient developed bilateral pulmonary infiltrates, received anti-fungal treatment and remained on lifelong Fluconazole; she was well at 2 years post transplant. The bilateral lung transplant recipient from the same donor had a BAL culture positive for coccidiodiomycosis on post transplant day +50, and subsequently died 9 months post-transplant with active coccidiodiomycosis despite Amphotericin B.
Demonstration of imputability or root cause:
This is likely to have been a donor-derived infection, with two recipients from a non-endemic area becoming infected with a geographically restricted agent which was isolated from donor BAL; however, the paper does not provide sufficient information to establish such level imputability, which is inferred. The donor chest-x-ray showed a 12 mm calcified lung mass which was not removed (felt to represent a possible past infectious process), with pulmonary calcifications less consistent with coccidiodiomycosis. Routine donor graft BAL fungal culture was positive on day +7 post transplant but the identification of Coccidioides spp was only made on post transplant day+47 by PCR. While the right liver lobe and lung transplant recipients developed active coccidiodiomycosis infection, the heart and bilateral kidney recipients did not receive prophylaxis and had no evidence of symptomatic infection. No serology of donor and recipients (pre and post-transplant) is mentioned in the paper. The authors do not describe detailed epidemiology and medical history for the donor and recipients, apart from mentioning that the donor had travelled to South America 4 months before death and that he had been coughing; the young left liver lobe recipient was said to have been born and lived in France; the other 5 recipients were adults and it is not mentioned whether or not they might have lived or travelled to an endemic area. Although molecular techniques were used to detect and or identify the Coccidioides strains, no molecular epidemiology work was carried out to analyse strain relatedness.
Suggest new keywords:
Donor-Related Coccidioidomycosis Transmitted Through Left Liver Transplant to a Child Recipient in a Non-Endemic Area. Tannè et al. Pediatr Infect Dis J. 2017 Jan 26
We can still reject this on the basis of poor description and low didactic value,as the text is difficult to follow. Alternatively, we can use it to illustrate the need to be clear in the description of events in order to claim proven donor imputability. The fact that the imputability grade is probable does not disqualify the paper, provided there is any value in adding it to the library. If you think that the the other Coccidioidomycosis records have already covered all the aspects necessary, we can leave this one out Perhaps we can call it probable because of infection in an nonendemic area and point out that unable to say proven because of the need to be more descriptive of symptomatology and timing.
Expert comments for publication:
In order to demonstrate proven donor imputability, a few criteria need to be met. These need to be clearly described to readers.