CDC: Balamuthia given to patients by Mississippi organ donor

[Shiloh]

Source: http://www.google.com/hostednews/ap/article/ALeqM5jWWYaONBnst-a1hheAxX37y9eW9gD9CM5ISG0

CDC: Rare infection passed on by Miss. organ donor

By HOLBROOK MOHR (AP)

JACKSON, Miss. ? An extremely rare infection has been passed from an organ donor to at least one recipient in what is thought to be the first human-to-human transfer of the amoeba, medical officials said Friday.

Four people in three states received organs from a patient who died at the University of Mississippi Medical Center in November after suffering from neurological problems, said Dave Daigle, a spokesman for the Centers for Disease Controls and Prevention.

Organs are routinely tested for HIV, hepatitis and other more common infections, but occasionally rare ones slip through.

"We test for the known harmful diseases, but there's not a test for every single pathogen out there," said Dr. Kenneth Kokko, medical director of kidney transplants at UMMC.

Two of the recipients are critically ill, but the others haven't shown symptoms, Daigle said. The CDC confirmed the presence of the organism, known as Balamuthia mandrillaris, in one of the recipients.

Dr. Shirley Schlessinger, a UMMC doctor and medical director of the Mississippi Organ Recovery Agency, would not say which states had patients receiving the organs.

The public should not be concerned, both Schlessinger and Daigle said.

Balamuthia mandrillaris is a microscopic parasite found in soil that causes encephalitis in humans, horses, dogs, sheep and nonhuman primates. Scientists think people get infected by breathing it in, but it can also pass into the blood through a cut or break in the skin. It can be especially dangerous to people undergoing organ transplants, whose immune systems are purposely weakened so their bodies don't reject their new organs.

Human infections are very rare: Only about 150 cases have been reported worldwide since the disease was first identified in 1990. But it can be hard to diagnose because few laboratories test for it and many doctors don't know about it. Some cases are not identified until autopsy, according to the CDC.

"The thing we don't want to happen is for people to take this rare and extraordinary anomaly and think it speaks to a lack of safety," she said. "It's very rare so the likelihood that this will happen again (is small), I mean, it's rarer than rabies."

There are risks to transplants and doctors can't test for everything, but the potential benefits far outweigh the risks, she said.

AP Medical Writer Mike Stobbe in Atlanta contributed to this report.

 

[Shiloh]

Re: CDC: Rare infection passed on by Miss. organ donor

Re: CDC: Rare infection passed on by Miss. organ donor

Source: http://www.clarionledger.com/article/20091222/NEWS/912220349/Parasite+altering+organ+donation

Parasite altering organ donation
2 recipients critical as policies assessed

Gary Pettus ? gpettus@clarionledger.com ? December 22, 2009

Two patients who received organs at the University of Mississippi Medical Center from a donor with an undetected, rare parasite remained in critical condition Monday.

The unusual case could lead to changes in donor policies, officials say.

The organs sickened two of four recipients. The other two patients have shown no harmful symptoms.

"Almost every day since we learned about this, there's been a national conference call involving transplant professionals, donor professionals, experts in every field," said Kevin Stump, CEO of the Mississippi Organ Recovery Agency, which accepted the organs.

"There probably will be some policy changes in the very near future.

"What they will be is being very much discussed across the United States."

Names of the donor and recipients are not being released, but doctors said the recipients are in three Southern states. The transplants were performed in late November.

UMC - the only transplant center in the state - had performed testing to eliminate the possibility of infection or disease.

The organs were then offered to MORA, which accepted them.

Dr. William Cleland, chief medical officer of University Hospitals and Health System, reported the illnesses on Friday.

"This disease is so extraordinarily rare that we can't imagine that anyone else would contract it from transplantation," said Dr. Shirley Schlessinger, the medical director for MORA.

"We don't believe anyone else is at risk of this. It has never been identified in an organ donor before and has never been transmitted in an organ transplant previously.

"We have never diagnosed a case of it in Mississippi."

The parasite was identified by the Centers for Disease Control and Prevention in Atlanta as Balamuthia mandrillaris, an amoeba that causes encephalitis, or inflammation of the brain, in humans, horses, dogs, sheep and nonhuman primates.

On Friday, the CDC confirmed the presence of the amoeba in one of the recipients. The amoeba can live in soil or water and may enter the body through the respiratory tract or the skin.

(2 of 2)

About 150 cases have been reported worldwide since 1990, and fewer than 70 have been reported in the United States since 1986.

Still, the case linked to UMC "will lead to a lot of dialogue," Schlessinger said.

"At this point, there is not a commercially available test for this.

The CDC is trying to identify the technology that could lead to one.

"But, unless you have some reason to expect this, it's not something you would test for, because it's so rare.

"It may be that through the national discussion, by putting our heads together, we can come up with additional ways to stratify donors.

"In this case, the donor didn't meet any of the high-risk criteria out there right now."

The risk of transmitting a disease through a transplant "can never be zero," said Joel Newman, spokesman for the United Network for Organ Sharing, which administers the nation's only organ procurement and transplant network, as established by Congress.

"There are a certain number of tests that can be performed, and the medical history of the donor can be obtained from the family.

"But you have a limited time to act from the time death is declared to the time a transplant is medically possible.

"It's normally a 24- to 36-hour window.

"It would be hard for me to say what could have been done in this case, but ... it stresses the urgency needed for very careful screening.

"It may be that there is a new screening question that can be asked, or a new test that can be done to minimize this risk."

The donor in this case had been a patient at UMC for a few days before he died "unexpectedly," Schlessinger said. He had been diagnosed with an autoimmune disorder.

The CDC later confirmed that his illness was caused by the rare amoeba.

In cases of disease transmission, "People get more concerned about transplants," Stump said.

"But everything that is mandated to screen organ donors was done in this case, even above and beyond what's called for.

"Even when everything is done that is humanly possible, there is still a risk.

"But we're always trying to make the donations of organs and transplantation as safe as possible."

To comment on this story, call Gary Pettus at (601) 961-7037.

 

[alert]

Re: CDC: Rare infection passed on by Miss. organ donor

Re: CDC: Rare infection passed on by Miss. organ donor

http://www.promedmail.org/pls/otn/f..._BACK_PAGE,F2400_P1001_PUB_MAIL_ID:1000,80571

Archive Number 20091222.4309
Published Date 22-DEC-2009
Subject PRO/EDR> Amebic meningoencephalitis, organ transplant - USA (02): (MS)

AMEBIC MENINGOENCEPHALITIS, ORGAN TRANSPLANT - USA (02): (MISSISSIPPI)
**********************************************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

[1] New York Times report
[2] [3] Comments

******
[1] New York Times report
Date: Fri 18 Dec 2009
Source: New York Times/International Herald Tribune [edited]
<http://www.nytimes.com/2009/12/19/health/19transplant.html>


Health officials reported on Friday [18 Dec 2009] that 2 transplant
patients are critically ill with a rare brain infection that was
transmitted to them by kidneys taken from a donor at the University
of Mississippi Medical Center in Jackson.

The same infection probably killed the organ donor, but it was not
diagnosed; his doctors thought he had an autoimmune disease. 2 other
patients also received heart and liver transplants from the donor,
but neither has become ill. The transplants took place in November
[2009], in 3 states. A spokeswoman for the university declined to say
where the recipients were, citing patient confidentiality.

3 weeks after their transplant surgeries, the kidney recipients
became ill abruptly, within hours of each other, with seizures, a
change in mental status and fever, said Dr Eileen Farnon, an
epidemiologist at the Centers for Disease Control and Prevention,
which is investigating the cases. A doctor noted that both were
transplant recipients, and immediately suspected that they might have
contracted an illness from the donor.

Subsequent tests of tissue left from the deceased donor found the
infection, which was also diagnosed in the patients. The patients are
being treated with a mixture of antimicrobial drugs.

The infection is caused by an amoeba, _Balamuthia mandrillaris_,
which lives in soil and water. Only about 70 cases have ever been
identified in the United States. Nearly all have been fatal. The
current cases are the first to have been found in transplant
recipients. Although infections from transplants are uncommon, there
have been cases in which recipients contracted West Nile virus,
rabies, and other infections.

[Byline: Denise Grady]

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

******
[2] Comments
Date: Tue 22 Dec 2009
From: LW Preston Church <Preston.Church@va.gov> [edited]


The moderator wonders if _Balamuthia_ could be present as an
asymptomatic infection, but the cited report notes that the donor
died after suffering "neurologic problems" so it is likely this was
undiagnosed but not asymptomatic.

It may be worth noting that not all free-living amoebae would pose
the same risk for organ transplantation. _Naegleria_ is directly
neuroinvasive through the cribriform plate into the olfactory tract
and has not been demonstrated outside the CNS (although myocarditis
has been reported in conjunction with PAM, _Naegleria_ have not been
identified in the myocardium).

None of 8 recipients of organs from 2 infected donors developed
subsequent evidence of infection (Bennet WM et al, Am J
Transplantation 2008; 8: 1334-5 and Kramer MH, Lerner CJ, Visvesvara
GS. J Clin Micro, 1997; 35: 1032-3.)

_Acanthamoeba_ and _Balamuthia_, on the other hand, are probably
acquired via the gastrointestinal or respiratory tracts and
disseminated infection is well known.

--
LW Preston Church, MD
Hospital Epidemiologist
Ralph H Johnson Veterans Administration Medical Center (VAMC)
Charleston SC
USA
<Preston.Church@va.gov>

******
[3] Comments
Date: Sun 20 Dec 2009
From: Maya Kimchi <kimchi.maya@gmail.com> [edited]


I would like to reply to the posting "Amebic meningoencephalitis,
organ transplant - USA (MS)" published today [20 Dec 2009]. Since my
final project is on rabies, I don't understand how it was possible
that the organs from a patient, who had died after showing neurologic
signs, were taken.

Because of the risk of rabies no organ transplant should be allowed
if the donor had neurological signs before his death. This rule was
[adopted] after the death of 16 people from rabies as a consequence
of organ transplantation.

--
Maya Kimchi
Veterinary student
<kimchi.maya@gmail.com>

[ProMED-mail thanks Dr Preston Church and Maya Kimchi for their
comments. It was indeed mentioned that the donor had neurological
problems. The fact that _Acanthamoeba_ and _Balamuthia_ can infect
humans through the gastrointestinal tract may explain that the
infection was seen outside the brain. The notion in the New York
Times article above, that the doctors thought that the patient had an
autoimmune disease is interesting. Autoimmune diseases are often
systemic affecting more than a single organ.

Information on _Balamuthia mandrillaris_ can be found at
<http://www.dpd.cdc.gov/dpdx/HTML/FreeLivingAmebic.htm>
and its life cycle at
<http://www.dpd.cdc.gov/dpdx/HTML/Frames/A-F/FreeLivingAmebic/body_FreeLivingAmebic_balamuthia.htm>.
- Mod.EP]

 

[Emily]

Re: CDC: Rare infection passed on by Miss. organ donor

Re: CDC: Rare infection passed on by Miss. organ donor

Second cluster of patients with transplant-transmitted Balamuthia was confirmed at CDC on August 27, 2010.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5936a1.htm?s_cid=mm5936a1_w

Balamuthia mandrillaris Transmitted Through Organ Transplantation --- Mississippi, 2009
Weekly
September 17, 2010 / 59(36);1165-1170

On December 14, 2009, a physician in Mississippi contacted CDC to report possible transplant-transmitted encephalitis in two kidney transplant recipients who shared the same organ donor. Histopathologic testing of donor autopsy brain tissue at CDC showed amebae, and subsequent testing of specimens from the donor and the two kidney recipients confirmed transmission by transplantation of Balamuthia granulomatous amebic encephalitis (GAE), a rare disease caused by Balamuthia mandrillaris, a free-living ameba found in soil (1). One kidney recipient, a woman aged 31 years, died; the other recipient, a man aged 27 years, survived with neurologic sequelae. Recipients of the heart and liver from the same donor received preemptive therapy and have shown no signs of infection. The donor, a previously healthy boy aged 4 years, was presumed to have died from acute disseminated encephalomyelitis (ADEM), an autoimmune neurologic disease, after infection with influenza A. An investigation was conducted by the state health departments in Mississippi, Kentucky, Florida, and Alabama and CDC to characterize the cases, elucidate possible exposures in the donor, and develop recommendations for early detection and prevention. This is the first reported transmission of Balamuthia by organ transplantation. Clinicians should be aware of Balamuthia infection as a potentially fatal cause of encephalitis. Organ procurement organizations (OPOs) and transplant centers should be aware of the potential for Balamuthia infection in donors with encephalitis of uncertain etiology, and OPOs should communicate this elevated risk for infection to transplant centers so they can make an informed risk assessment in the decision to accept an organ.
[snip]
This report is the first to describe transmission of Balamuthia through organ transplantation. However, a second cluster of patients with transplant-transmitted Balamuthia was confirmed at CDC on August 27, 2010 (2). Balamuthia infection is extremely rare, with fewer than 200 human cases recognized worldwide since Balamuthia was found to be a human pathogen in 1990 (3,4). The true magnitude of disease caused by Balamuthia is unknown because Balamuthia GAE often is misdiagnosed as other neurologic diseases (1,3). Once infection progresses to encephalitis, it is almost always fatal. Infection occurs in both immunocompromised and otherwise healthy persons, and often in children, although cases have occurred in patients across the age spectrum (5). Because of the rarity of Balamuthia GAE, risk factors are poorly defined, but might include exposure to soil or stagnant water, young age, and Hispanic ethnicity (3).