Adverse Occurrence type:
Alerting signals, symptoms, evidence of occurrence:
Rapidly fatal, disseminated coccidiomycosis developed after organ transplantation in a liver (recipient # 1) and a kidney recipient (recipient #2) but not the other kidney recipient who received pre-emptive anti-fungal therapy. Recipent #2. On day 11 after 28 yr old man received a kidney transplant, creatinine rose to 4.2 followed by steroid therapy for 3 days for rejection. On day 17, he developed fever, sepsis syndrome, respiratory failure, altered mental status, hypotension. Bronchial washings were negative on exam but later cultures grew C immitis. On day 19 he died and autopsy showed disseminated microabscesses with C immitis in the marrow, lungs, kidney, heart, thyroid, pancreas, brain, testes, liver, spleen. Pretransplant test for C immitis antibodies was negative. This shows the importance of rapid reporting of infections in organ recipients so that unaffected organ recipients from the same donor can be evaluated and given prophylactic treatment.
Demonstration of imputability or root cause:
Level 4. Certain, Proven transmission. Serious infection, same organism in donor (active at donation) and more than one organ recipient. The recipients had never lived in or visited an endemic area. Donor was young man with headache, malaise, back pain, near-syncope who had cardiac arrest in emergency room and days later became an organ donor. A thorough medical history of the donor was not obtained before donation, but it was noted that he had a remote history of treated coccidiomycosis. After recipients were treated for coccidiomycosis, added information was discovered about the donor: in prison 5 years, released one year before death and 5 years before death he had coccidiomycosis of the skin, vertebral bodies, and sternum with prolonged hospitalization and multiple surgical procedures and lifelong antifungal medicine recommended to him. The brain autopsy report was available one month after transplant, showing the donor had Coccidioides immitis infection in the brain.