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Eastern equine encephalitis transmitted via solid organ transplantation

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November 5, 2018

Researchers documented the first reported transmission of eastern equine encephalitis through solid organ transplantation and warned clinicians to be aware of the virus as a cause of transplant-associated encephalitis.

Two of the three patients who developed eastern equine encephalitis virus (EEEV) infection after receiving organs from the same donor died.

“While rare, EEEV causes one of the most severe arboviral diseases in North America, with approximately 30% fatality among reported cases,” Stephanie M. Pouch, MD, assistant professor of medicine at Emory University School of Medicine, and colleagues wrote in Clinical Infectious Diseases. “While transplant and transfusion transmission of other arboviruses has been documented, to our knowledge, these modes of transmission have not been reported for EEEV.”

According to Pouch and colleagues, in the fall of 2017, three transplant recipients who received a heart, liver and lungs from one donor developed encephalitis within 1 week of transplantation. The researchers reported testing serum, whole blood, cerebrospinal fluid and tissue from the three recipients and the donor for evidence of EEEV. They reviewed the donor and recipient medical records and tested remaining specimens from blood donors on the suspicion that blood transfusion may have been a possible source of the infection in the donor, a women in her 40s who died from a gunshot wound to the head and had received eight units of blood components before her heart, liver and lungs were recovered. According to the report, the woman was not reported to have had recent febrile illness or neurologic symptoms and no evidence of active infection was found during standard laboratory screening conducted by the organ procurement organization.

The heart transplant recipient was a woman in her 40s with a history of breast cancer and a non-ischemic cardiomyopathy related to doxorubicin toxicity, Pouch and colleagues reported. She developed headache, hypotension, persistent fever and progressive altered mental status 7 days after transplantation, they said. Testing confirmed EEEV. Four months after transplantation, she died after developing sepsis from what Pouch and colleagues said may have been caused by an intestinal perforation.

The liver transplant recipient was a woman, also in her 40s, with a history of autoimmune hepatitis and chronic pancytopenia, according to the report. One day after her transplant in the fall of 2017 — her second liver transplant — she developed a high fever despite receiving broad-spectrum antimicrobials, Pouch and colleagues said. Five days later, “she experienced confusion, which progressed to obtundation requiring intubation,” they wrote. Testing confirmed EEEV and the patient died 3 months after transplantation after care was withdrawn.

The lung transplant recipient was a woman in her 50s with end-stage chronic obstructive pulmonary disease who developed a fever and an altered mental status with the inability to follow commands 7 days after transplantation, according to the report. Testing detected EEEV RNA, but the woman survived.

“No recent human cases of EEEV disease in or around the donor’s county of residence were reported to ArboNET. However, EEEV disease cases in horses and one positive mosquito pool were identified in nearby counties within an approximate 75-mile radius in the 3 months prior to her death,” Pouch and colleagues wrote.

They said EEEV infection directly contributed to one of the deaths in the organ recipients and likely contributed to the other.

“Clinicians should remain vigilant for clusters of encephalitis following solid organ transplantation,” Pouch and colleagues wrote. “EEEV or other arboviral infections should be considered in recipients who develop encephalitis after transplantation, particularly if donors and recipients reside in endemic areas of the United States.” – by Marley Ghizzone

Disclosures: Pouch reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

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