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Adverse Occurrence type:
First reported case of transfusion-transmitted Japanese Encephalitis Virus (JEV). Frequency unknown.
Time to detection:
Symptoms onset on day 14 and overt encephalitis on day 16 after transfusion of implicated red blood cells (RBC) unit. JEV RNA and IgM detected in the patient's CSF on day 28 after transfusion.
Alerting signals, symptoms, evidence of occurrence:
Index case: a 52-year-old man with advanced chronic obstructive pulmonary disease underwent double lung transplantation in an endemic area for JEV. The patient required transfusions of packed RBC for anemia 41 and 43 days after transplantation. 57 days after transplantation and 14‒16 days after transfusions, he had a transient maculopapular rash and fever with progression to severe encephalitis two days after the rash manifestation. MRI abnormalities involving the basal ganglia, raised the possibility of flaviviral encephalitis; JEV RNA was detected in serum, cerebrospinal fluid, and bronchoalveolar lavage fluid. The patient died 84 days after transplantation. A second recipient with leukemia received platelets from the same donor after undergoing chemotherapy. This patient remained asymptomatic; JEV infection was confirmed by IgM seroconversion. A third patient received plasma transfusion and died 14 days later of respiratory failure; this patient could not be assessed for JEV.
Demonstration of imputability or root cause:
CSF pleocytosis and elevated protein levels. JEV detected in the CFS of the index case and in the blood donation specimen of transfused RBC had indistinguishable sequence. Phylogenetic comparison with other JEV sequences from GenBank showed that the index case and blood donor isolates belonged to JEV genotype 1, a circulating genotype common in southern China. Blood donor from Hong Kong, with no recent travel to other JEV-endemic regions. The patient was treated in air-conditioned rooms throughout his hospitalization. A vector surveillance showed that C. tritaeniorhynchus mosquitoes had not been detected in broader location of hospitals one month before and during this patient hospitalisation. Therefore, mosquito-borne transmission was considered unlikely. The onset of symptoms was 57 days after the transplantation date, longer than the usual 5‒15-day incubation period for JEV, but infection transmission through the transplanted lungs was ruled out by negative testing in the other organ recipients from the same multiorgan donor (1 liver and 2 kidneys, IgM negative on day 71, 76 and 83 post transplant, respectively; donor's serum sample not available for JEV testing).
Suggest new keywords:
JEV RNA; cerebrospinal fluid; bronchoalveolar lavage fluid; transfusion-transmitted
Cheng V, Sridhar S, Wong S, Wong S, Chan J, Yip C, et al. Japanese Encephalitis Virus Transmitted Via Blood Transfusion, Hong Kong, China. Emerg Infect Dis. 2018;24(1):49-57
Add Japanese Encephalitis Virus to the adverse occurrence taxonomy (EP) Ines: Need key words; add place where this happened (endemic for JE) --> OK (EP)
Expert comments for publication:
Consistent with other pathogenic flaviviruses, JEV can be transmitted via blood components. Of note, 24 days elapsed between the time of blood donation and transfusion to the index patient, indicating that the virus can remain viable in packed red blood cells over a prolonged period of time.