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Adverse Occurrence type:
There are seven publications reported in the literature with a dozen of cases of probable/proven transmission of cryptococcosis via solid organ transplantation (2018).
Time to detection:
Very late, on postoperative days (POD) 67, 90, and 106 for the kidney, lung and liver recipient, respectively.
Alerting signals, symptoms, evidence of occurrence:
LUNG RECIPIENT: BAL cultures obtained immediately post-transplantation grew C. neoformans on POD 5 but fungal blood cultures and serum cryptococcal antigen were negative. Since BAL cultures obtained on POD 12 were negative but BAL Aspergillus galactomannan (GM) was positive, the decision was to continue voriconazole at treatment doses. Discharged on POD 23, the patient was readmitted on POD 90 with fever and cough. BAL fungal culture grew C. neoformans. KIDNEY RECIPIENT: presented on POD 67 with a week of generalized weakness, subjective fevers, poor appetite, decreased ambulation, and confusion. He was diagnosed with cryptococcal meningitis (positive CSF cultures and CSF cryptococcal antigen positive at 1:1280). LIVER RECIPIENT: presented on POD 106 with 4-day history of dizziness and headache, intermittent blurry vision, diplopia, and unsteady gait. Blood cultures drawn on admission grew C. neoformans.
Demonstration of imputability or root cause:
Donor blood cultures at the time of procurement were negative, however became positive for yeast after 5 days of incubation, subsequently identified as Cryptococcus neoformans approximately 8 days after organs had been transplanted. Bronchoalveolar lavage (BAL) donor cultures also grew C. neoformans after 5 days of incubation. The imputability is weak in terms of microbiology as it was not possible to assess if Cryptococcus neoformans was the same strain in the donor and all the recipients. On the other hand, three recipients from the same donor infected with the same microorganism that was also the cause of death of the donor make it highly probable.
Suggest new keywords:
Cryptococcus neoformans, meningoencephalitis, donor derived infection, cryptococcal antigen
1) Camargo JF, et al. A cluster of donor-derived Cryptococcus neoformans infection affecting lung, liver, and kidney transplant recipients: Case report and review of literature. Transpl Infect Dis. 2018 Apr;20(2):e12836. 2) 10 Years of DTAC Experience With Donor-Derived Cryptococcus Transmission in Solid-Organ Transplantation in the United States. Open Forum Infect Dis. 2018 Nov; 5(Suppl 1): S59.
Expert comments for publication:
Donors with meningoencephalitis of unknown origin where infection is a possibility should only be considered with great caution and under exceptional circumstances. It should also be noted that donor derived infection could present beyond one month after transplantation specially for fungal and parasitic infections. Any atypical symptom or positivity in sample cultures should raise the suspicion of donor derived infection. It is compulsory to communicate the possibility of donor derived infection to all recipients from the same donor.