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Adverse Occurrence type:
The frequency of donor derived Mycobacterium tuberculosis infection associated with history of Latent Mycobacterium Tuberculosis Infection (LTBI) in the absence of known active TB is unknown; the rate of transmission from a donor with active MTB infection is thought to be around 30%; In this report, there were four recipients (lungs, heart, liver, kidneys), with one transmission (bilateral lung recipient).
Time to detection:
Alerting signals, symptoms, evidence of occurrence:
Donor: Organ donor. The adult organ donor was admitted to hospital following a motor vehicle crash. A chest computed tomography (CT) scan on admission revealed diffuse nodular infiltrates consistent with pulmonary contusions, but also raised suspicion for TB. A Tuberculin Skin Test (TST) was negative and Interferon Gamma Release Assay (IGRA) was indeterminate. Endotracheal aspirate and bronchoalveolar lavage were negative for acid-fast bacilli (AFB) by smear and culture. Nucleic acid amplification testing (NAAT) was not performed. The donor had immigrated to the United States approximately 8 years earlier and had been incarcerated several times; he had a positive TST 2 years before death but had never received a diagnosis of TB disease. Bilateral lung recipient: the recipient developed a persistent cough and fatigue 3 months post transplant. Chest CT revealed bilateral pleural and pericardial effusions. Cultures from effusions and sputum yielded M. tuberculosis. The US born recipient had minimal foreign travel and no epidemiologic links to other TB cases. Pre-transplant TST and IGRA were negative. Initially, the recipient’s TB was thought not to be donor-derived because of the organ donor’s negative pre donation TB evaluation. The recipient responded well to TB treatment. Three other recipients of 2 kidneys, liver and heart did not develop MTB infection.
Demonstration of imputability or root cause:
The organ donor was epidemiologically linked after death to an ongoing TB outbreak in the community, with the infecting strains being all of of the same genotype. Spoligotyping (a polymerase chain reaction [PCR]–based method) and analysis of 24-locus variable-number tandem repeat of mycobacterial interspersed repetitive units (VNTR-MIRU) (a PCR method that analyses specific regions of the genome) were performed, with matching profiles. Subsequent whole-genome sequencing and phylogenetic analysis also confirmed genetic relatedness of the strains, which were very uncommonly seen in the USA.
Tuberculosis in solid-organ transplant recipients: consensus statement of the group for the study of infection in transplant recipients (GESITRA) of the Spanish Society of Infectious Diseases and Clinical Microbiology.
Mycobacterium tuberculosis Infections in Solid Organ Transplantation: Guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation
Suggest new keywords:
TB; Mycobacterium tuberculosis; latent tuberculosis; IGRA; TST; spoligotyping; genotyping
, Interferon Gamma Release Assay; Ziehl-Nielsen; LTBI,
whole genome sequencing, lung transplant, pericardial effusion, pleural effusion, cough, fatigue
Kay A, Barry PM, Annambhotla P, et al. Solid Organ Transplant–Transmitted Tuberculosis Linked to a Community Outbreak — California, 2015. MMWR Morb Mortal Wkly Rep 2017;66:801–805. Aguado J, et al. Tuberculosis in solid-organ transplant recipients: Consensus statement of the Group for the Study of Infection in transplant recipients (GESITRA) of the Spanish society of infectious diseases and clinical microbiology 2009. Clinical Infectious Diseases; 48(9): 1276-1284 Subrumanian AK, Morris MI, et al. Mycobacterium tuberculosis infections in Solid Organ Transplantation 2013 Am Journal of Transplantation;13:68-76 Ruiljer BN, Wjingaarden AKS, et al. Donor-derived tuberculosis via orthotopic liver transplantation. The Netherlands Journal of Medicine 2017; 75(9): 415 - 417 Santoro-Lopes G, et al Tuberculosis Recommendations for Solid Organ Transplant Recipients and Donors 2018 Transplantation; 102(2S): p S60–S65 Hernández-Hernández E, Alberú J, González-Michaca L, et al. Screening for tuberculosis in the study of the living renal donor in a developing country. Transplantation. 2006;81:290–292.
Expert comments for publication:
Organs from donors with history of either active or latent tuberculosis who have received appropriate treatment for a minimum of 6 months can be considered for transplantation. Recognition of latent or undiagnosed active TB in deceased donors can be difficult but is essential in order to mitigate recipient harm. Detailed medical and social history should inform appropriate investigations, but there are known limitations. The 48–72 hour window required to interpret a TST is often incompatible with organ donation, and the test performance of both TST and IGRA has not been fully evaluated in this context. These tests have good specificity but negative results do not exclude previous exposure to MTB neither do they differentiate between active and latent infection. Recommendations from professional groups have been published which must be interpreted in the context of local epidemiology, resources and clinical experience.