Francisella tularensis

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Adverse Occurrence type: 
MPHO Type: 
Estimated frequency: 
Tularemia is a disease caused by the bacterium Francisella tularensis. This organism has been previously reported to be transmitted through organ transplantation.
Time to detection: 
Symptoms began about 5 days post transplant, and about 10 days post transplant there was recognition that the event might be donor-derived.
Alerting signals, symptoms, evidence of occurrence: 
Two kidney recipients developed fever and septic shock, with growth of gram negative bacilli in cultures; one kidney recipient died, and one survived with appropriate antibiotic treatment. The other organ recipient, a heart transplant patient, was ill post-transplant, but was on antibiotics that treat tularemia so it is unclear whether transmission occurred in this patient (would judge as possible).
Demonstration of imputability or root cause: 
Organism detected from donor spleen tissue, and from lagomorph (rabbits or rabbit like mammals) bone marrow found near donor residence. A dedicated podcast of the Emerging Infectious Diseases series is available at the following link:
Imputability grade: 
3 Definite/Certain/Proven
Suggest new keywords: 
gram negative bacteria
Suggest references: 
Francisella tularensis Transmission by Solid Organ Transplantation, 2017. Nelson CA, et al. Emerg Infect Dis. 2019 Apr;25(4):767-775
Add Francisella in the adverse occurrence taxonomy. Consider adding the podcast link? (EP)
Expert comments for publication: 
Francisella tularensis is a highly pathogenic organism, so rapid clinical recognition is critical to avoid high morbidity and mortality. In addition, it is identified as a potential bioterrorism agent ("Tier 1" in US), as it has a low infective dose and high capacity to spread via aerosolization. It has been reported to be transmitted to laboratory personnel through exposure to culture plates. Tularemia can be found in various areas of the world but appears to be increasing in incidence in the United States, being transmitted through ticks and contact with rabbits and other mammals (hence the term "rabbit fever"). The growth of gram negative bacilli in the blood of a patient with epidemiologic risk factors should trigger suspicion, with immediate action taken for appropriate laboratory infection control and confirmation of the organism in a public health laboratory. There are many bacteria that can be transmitted through organ transplantation causing septic shock in multiple recipients, and tularemia should be added to the differential.