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Adverse Occurrence type:
Donor-derived TB is reported to account for <5% of TB in solid organ transplants, but the source of Mycobacterium tuberculosis MTB) infection is infrequently determined (Mortensen 2014). The rate of transmission from a donor with active MTB infection is thought to be around 30%; no data exists for donor with latent MTB infection (LTBI)
Time to detection:
The liver recipient time to detection posttransplant was two months, based on the exposure history of the anesthesiologist. The kidney recipient time to detection was not listed, although time of death was one year posttransplant.
Alerting signals, symptoms, evidence of occurrence:
This case report describes occupational exposure to a renal transplant recipient with undiagnosed INH-resistant, donor derived Mycobacterium tuberculosis who underwent intubation by an anesthesiologist for repair of a wound infection 2 months post transplant. 6 months following the intubation exposure, the anesthesiologist developed active pulmonary MTB with recurrent pleural effusions requiring multiple drainage procedures and anti-MTB therapy; the renal transplant recipient was diagnosed with MTB infection of the wound, graft, urinary tract and lungs. The second kidney recipient dies 1 year post transplant but cause was not disclosed in the paper. The liver recipient from the same donor died from MTB approximately one year post transplant, although the timing of diagnosis was not reported. The donor was a 67 year old immigrant from Russia with history of active MTB 40 years earlier requiring pneumonectomy. Possibly with INH-resistant MTB (INH was developed in 1952 - unknown drug therapy although may have received INH at the time of the donor's diagnosis). While the case report focused on the occupational exposure of the anesthesiologist, another important issue is the donor derived infection despite presumptive treatment with pneumonectomy and unclear drug therapy history.
Demonstration of imputability or root cause:
Method to demonstrate imputability was the DNA fingerprinting of the liver and kidney recipients as well as anesthesiologist, which was identical.
Donor-derived tuberculosis in an anesthetist after short-term exposure : An old demon transplanted from the past to the present
Diagnosis and management of tuberculosis in transplant donors: a donor-derived infections consensus conference report
Suggest new keywords:
INH resistance; interferon gamma test; pulmonary tuberculosis; liver transplantation ; kidney transplantation,
active tuberculosis; latent tuberculosis; tuberculosis; tuberculosis skin testing; TST; IGRA
1) Donor-derived tuberculosis in an anesthetist after short-term exposure : An old demon transplanted from the past to the present. Freytag et al. Anaesthesist. 2016 May;65(5):363- 2) Morris M, et al. Diagnosis and management of tuberculosis in transplant donors: a donor-derived infections consensus conference report. Am J Transplant. 2012;12: 2288–2300. 3) Clemente WA, et al. Recommendations for Management of Endemic Diseases and Travel Medicine in Solid-Organ Transplant Recipients and Donors: Latin America. Transplantation 2018;102(2): 193–208
Expert comments for publication:
Organs from donors with history of either active or latent tuberculosis who have received appropriate treatment for a minimum of 6 months can be considered for transplantation. Recognition of latent or undiagnosed active TB in deceased donors can be difficult but is essential in order to mitigate recipient harm. Detailed medical and social history should inform appropriate investigations, but there are known limitations. The 48–72 hour window required to interpret a TST is often incompatible with organ donation, and the test performance of both TST and IGRA has not been fully evaluated in this context. These tests have good specificity but negative results do not exclude previous exposure to MTB neither do they differentiate between active and latent infection. Recommendations from professional groups have been published which must be interpreted in the context of local epidemiology, resources and clinical experience.