On July 1, 2004, CDC reported laboratory confirmation of rabies
as the cause of encephalitis in an organ donor and three organ
recipients at Baylor University Medical Center (BUMC) in Dallas,
Texas (1).
Hospital and public health officials in Alabama, Arkansas,
Oklahoma, and Texas initiated public health investigations to
identify donor and recipient contacts, assess exposure risks,
and provide rabies postexposure prophylaxis (PEP). As of July 9,
PEP had been initiated in approximately 174 (19%) of 916 persons
who had been assessed for exposures to the organ recipients or
the donor. As a result of its public health investigation, the
Arkansas Department of Health determined that the donor had
reported being bitten by a bat (Frank Wilson, M.D., Arkansas
Department of Health, personal communication, 2004).
On July 7, CDC was notified of an
additional organ transplant patient at BUMC who had died of
encephalopathy of unknown origin in early June. This case was
detected as part of an ongoing review of transplant-patient
autopsies. The patient, who had end-stage liver disease, had
received a liver transplant at BUMC in early May 2004. The
patient remained hospitalized with transplant-related
complications and began having neurologic abnormalities in early
June, progressing to seizure, coma, and death. On July 7,
pathologists at BUMC identified intracytoplasmic inclusions,
suggestive of rabies, in neurons in multiple areas of the brain.
Specimens from the recipient were
sent to CDC on July 7, and direct fluorescent antibody and
immunohistochemical staining procedures confirmed the presence
of rabies viral antigens in multiple areas of the brain,
including the hippocampus, midbrain, pons, medulla, and
cerebellum. Similar to the findings with the three previously
known rabies-infected transplant recipients, preliminary
antigenic characterization of the agent was consistent with a
rabies virus variant associated with insectivorous bats. On July
8, CDC laboratory testing of tissues and serum from the donor
who provided the liver yielded no evidence of infection with
rabies virus.
Review of surgical procedures at
BUMC determined that a segment of iliac artery recovered from
the donor subsequently determined to have rabies had been stored
at the facility for future use in liver transplants. This artery
segment subsequently was used in the transplantation of the
liver in the most recently identified rabies-infected recipient.
Investigation of rabies transmission sources is ongoing,
although current evidence suggests that the artery segment
originating from the rabies-infected donor likely is the source
of the latest rabies infection. Identification of contacts of
this liver recipient is under way, and initiation of PEP when
indicated or as appropriate is in progress.
References
-
CDC. Investigation of rabies infections in organ donor and
transplant recipients---Alabama, Arkansas, Oklahoma, and
Texas, 2004. MMWR 2004;53:586--9.
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