Transmission Of SARS‐CoV‐2 By Lung Transplantation

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Record number: 
MPHO Type: 
Estimated frequency: 
Transmission of a respiratory pathogen through lung transplantation is expected to occur but this is the first reported case in the literature.
Time to detection: 
3 days
Alerting signals, symptoms, evidence of occurrence: 
The donor had suffered severe brain injury in an automobile accident and quickly progressed to brain death during a two-day hospital admission. Computed tomography (CT) on admission showed areas of consolidation within the posterior right lower lobe interpreted as atelectasis and pulmonary contusion. SARS-CoV-2 RT-PCR testing was performed within 48 hours of procurement on a nasopharyngeal (NP) swab and resulted negative. Lower respiratory tract testing was not performed. This event happened during the 2020-2021 COVID-19 pandemic, a period of high transmission of SARS-CoV-2 in the local community. Both lungs donated and transplanted into a single patient; no other organs transplanted. Bilateral lung recipient: rapid SARS-CoV-2 RT-PCR performed on an NP swab was negative 12 hours before transplant. Due to the sudden worsening in respiratory status and evolving lung infiltrates on PTD 3, bronchoscopy was performed and BAL samples were collected from both lungs. The BAL fluid was sent for SARS-CoV-2 PCR testing along with a second NP swab. The NP swab was negative but the BAL sample was positive for SARS-CoV-2 RNA with a low cycle threshold (Ct) value, indicative of a high viral RNA copy number in the specimen. Repeat testing on the following day was positive on both tracheal aspirate and NP swab. BAL fluid obtained from the donor at the time of procurement was tested retrospectively at the transplant center and was SARS-CoV-2 RNA positive with a low Ct value. Persistently low cardiac index was noted on post-transplant day (PTD) 2, and a transthoracic echocardiogram revealed acute right ventricular dysfunction. On PTD 3, the patient developed worsening fever, hypotension and increased ventilator requirements. CT imaging of the chest showed multifocal consolidations. Gradual decline of the overall clinical status, death on PTD 61 (PCR Ct value of 29.3).
Demonstration of imputability or root cause: 
Follow up of health care personnel involved in the donation and transplantation of organs from the implicated donor: health care workers deemed to have had high risk exposure were offered testing; SARS-CoV-2 PCR was performed 5 or more days post-exposure and one thoracic surgeon involved in the preparation and implantation of the lungs tested positive for SARS-CoV-2 four days after the procedure. Of note, there was exposure to donor secretions when cutting off the bronchial staple line. No other health care personnel tested positive during the screening period. Molecular epidemiology: Five of six sequences analysed were identical at the consensus level: donor right BAL (PTD 0), recipient left BAL (PTD 3), recipient right BAL (PTD 3), recipient tracheal aspirate (PTD 4), recipient NP swab (PTD 4). Although the virus from the surgeon differed at just one position relative to the donor and recipient samples, an alternative source of infection is highly unlikely since the lineage associated with the donor, recipient, and surgeon sequences was quite distinct from other viral sequences circulating in that community at that time. No other organs were donated and therefore the risk of transmission to non-lung recipients was not assessed.
Imputability grade: 
3 Definite/Certain/Proven
Suggest references: 
Transmission Of SARS‐CoV‐2 By Lung Transplantation
This is Oscar Len revising the case report. Second review IUL; ready for uploading please New AO type added: SARS‐CoV‐2 (EP)
Expert comments for publication: 
Donor testing: Where infra-structure permits, testing within 24 hours from the point of organ donation is preferable. Sampling of lower respiratory secretions in addition to nasopharyngeal sampling is important in the diagnosis of unsuspected SARS-CoV-2 infection. This adds sensitivity to the screening process during deceased organ donor characterisation and many groups advocate it to be essential, particularly in the case of lung donation. Other publications referenced in this record address the same issue. Transmission of SARS-CoV2 through donated lungs from asymptomatic individuals is not unexpected, particularly during periods of high transmission in the community; transmission through other organs remains a theoretical possibility but it has not been demonstrated so far. High morbidity from COVID-19 , specially in the setting of early post -lung transplantation, highlights the importance of detailed donor and recipient characterisation as well as great infection prevention and control (IPC) in the early post-transplant period. Strict adherence to local IPC guidance is important to minimise risk of health care associated infection, including health care personnel. Collection of lower respiratory tract secretions are generally aerosol generating procedures hence the correct IPC precautions must be observed according to local guidance. Endotracheal aspiration under closed circuit is an alternative option to be considered. Adherence to good practice and appropriate use of personal protective equipment is effective in minimising risks to health care workers. As far as the molecular epidemiology analysis is concerned, it is important to note that consensus between two sequences per se is not sufficient to demonstrate impartibility, as only a small sampling of cases are being sequenced during the current pandemic; however, the authors included background sequences from the hospital and from the wider community too. All facts taken into account, backed by the molecular evidence, support a cluster of infection.