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Adverse Occurrence type:
Recognition of Ureaplasma urealyticum as a cause of fatal hyperammonemia in lung recipients within days of transplantation has been reported since 2015. Two subsequent papers reporting donor testing of infected recipients compared to noninfected recipients indicated that all cases of fatal hyperammonemia and Ureaplasma infection occurred in donors and recipients who screened BAL (bronchoalveolar lavage) positive for Ureaplasma, while no cases were found from donors and recipients who screened negative. There is no available estimated frequency, but a paper by Fernandez et al of 29 lung recipients of 28 donors screened all donors for Ureaplasma. 4 donors were positive for Ureaplasma (14%), and their lung recipients all developed hyperammonemia, lung infiltrates and systemic inflammatory response syndrome requiring vasopressors (Fernandez R, Chi M, Ison et al. Am J of Resp and Critical Care Medicine 2017, 195(5)). The literature in this area is limited, but based on this study, indicates a significant transmission frequency (14%).
Time to detection:
Detection of symptoms occurs within 1-3 days of transplantation
Alerting signals, symptoms, evidence of occurrence:
Lung infiltrates, systemic inflammatory response syndrome, altered mental status, hyperammonemia, death within 1-3 days of transplantation. Trend towards greater incidence of grade 3 primary graft dysfunction, acute renal failure, acute rejection and 60 day mortality. Two cases reported of bronchial dehiscence. 100% mortality unless treated with antibiotics (macrolide plus doxycycline or quinolone) although antimicrobial therapy may not be 100% protective. Requires two antibiotics due to risk of resistance.
Demonstration of imputability or root cause:
Data is based on two reports - one report (Fernandez et al. listed above) of 4 lung donors who tested positive for Ureaplasma (culture/PCR) with pretransplant Ureaplasma negative recipients all resulting in recipients who became Ureaplasma culture/PCR positive and symptomatic. A second paper (also Fernandez et al. J of thoracic surgery 2017) reported on another case of probable donor-derived Ureaplasma parvum (pre-implantation BAL culture and PCR positive; tested retrospectively); the recipient had a negative pretransplant BAL followed by post transplant BAL culture and PCR positivity for Ureaplasma parvum, with clinical and radiological response to dual azithromycin and doxycycline.
Suggest new keywords:
systemic inflammatory response
1) Sequelae of Donor-derived Mollicutes Transmission in Lung Recipients. Fernandez R, et al. Am J Respir Crit Care Med. 2017 Mar 1;195(5):687-689 2) Donor-derived ureaplasma is a potentially lethal infection in lung allograft recipients. Bharat A, et al. J Heart Lung Transplant. 2017 Aug;36(8):917-918 3) Ureaplasma Transmitted From Donor Lungs Is Pathogenic After Lung Transplantation. Fernandez R, et al. Ann Thorac Surg. 2017 Feb;103(2):670-671
Add a new category for "Ureaplasma" in the bacterial infections' taxonomy - OK (EP)
Expert comments for publication:
This is an important and relatively newly recognized donor derived infection, particularly in lung recipients; consideration might be given to screening of donor lung BAL and post -transplant recipient testing, Sexually active donors with aspiration pneumonia may represent a risk for Ureaplasma presence in the lower respiratory tract but this is based on the observations from these few reported cases. Ureaplasma infection of the genito-urinary tract is common but it is not part of the normal respiratory tract flora; risk factors for its presence in donor lungs and associated mortality warrant the need for future studies to investigate the optimal strategies for Ureaplasma detection, prophylaxis and treatment. The papers included in this record discuss these issues.