Adverse Occurrence type:
Time to detection:
Alerting signals, symptoms, evidence of occurrence:
17 days after liver transplant a 56 year old male develpoed diplopia, difficulty walking and died on postop day 25. Autopsy showed Balamuthia granulomatous amebic encephalitis in brain and liver. Donor was a 27 year old landscaper who died of a presumed stroke. He had a large skin lesion on the back for 6 months (In Balamuthia amebic infection patients can have a skin lesion for 6-12 months before developing amebic encephalitis). Organ recipients would have the organ as the entry vehicle, and wouldn't have a history of a skin lesion entry site:
Demonstration of imputability or root cause:
Likely, probable transmission from donor. Both liver and kidney-pancrese recipients died of B mandrillaris infection but infection was not documented in the organ donor. B. mandrillaris DNA was detected in brain tissue by PCR for both liver and kidney-pancreas recipients. B. mandrillaris antigens were found in brain tissue of the K-P recipient and brain and liver tissue of liver recipient.The donor history was suggestive of infection because he had a skin lesion of 6 months duration and died of a catastrophic brain condition.
Transmission of Balamuthia mandrillaris through solid organ transplantation: utility of organ recipient serology to guide clinical management.
Balamuthia mandrillaris meningoencephalitis associated with solid organ transplantation--review of cases.
Emerging trends in free-living amebic infections of the brain: implications for organ transplantation.