In the Journals

Transplant recipient’s death from yellow fever highlights ‘great dilemma’

Amid a yellow fever outbreak in Southeastern Brazil, an unvaccinated kidney transplant recipient contracted the disease and died, highlighting a “great dilemma” physicians must contend with — advising immunocompromised patients about vaccination in areas affected by yellow fever, researchers reported in Clinical Infectious Diseases.

In a related editorial, Paolo A. Grossi, MD, PhD, professor of infectious diseases at the University of Insubria in Varese, Italy, noted that solid organ transplant survival rates have improved over the years, making transplant surgery a “durable therapy.”

“Most [solid organ transplant] recipients show excellent survival rates and the vast majority is rehabilitated to a normal life,” he wrote. “However, lifelong immunosuppressive regimens place them at increased risk of developing opportunistic and nonopportunistic infections. Further, they are less likely to develop a robust response to vaccines for routine and travel-related pathogens and live-attenuated vaccines have been historically contraindicated in immunosuppressed [solid organ transplant] recipients.”

Grossi said transplant physicians should be aware that globalization and climate change may be having an effect on the spread of infectious diseases.

“Studies suggest that longterm climate warming tends to favor the geographic expansion of several infectious diseases and that extreme weather events may foster opportunities for more clustered disease outbreaks or outbreaks at non-traditional places and time. The recent Brazilian urban outbreak of [yellow fever] is an example of this phenomenon,” Grossi wrote. “Transplant physicians should be aware of these changes and consider that [solid organ transplant] recipients may be sentinel for new outbreaks or emerging infections.”

The patient who died was 58 years old in February 1993 when he received a kidney allograft transplant from a deceased donor. He had a good outcome, had good renal function and was maintained with azathioprine, cyclosporine and low-dose prednisone, according to the report.

In December of 2017, almost 25 years after transplantation, he was admitted to the hospital, presenting with a fever lasting 2 days, malaise, nausea and vomiting. He lived 6 kilometers from a city park that contained remains of native forest where monkeys affected by yellow fever had been detected, the researchers reported. He was clinically well upon admission, but deteriorated and died 6 days after hospital admission. RT-PCR-confirmed that he was infected with yellow fever virus — the first reported case of yellow fever in a transplant recipient, according to the report.

Despite yellow fever being a vaccine-preventable disease, vaccination was not possible because of the patient’s immunosuppressed status.

“Vaccination may lead to viscerotropic vaccine disease, which may be fatal,” Lígia C. Pierrotti, MD, PhD, an infectious disease physician at the Hospital das Clinicas at the University of São Paulo, and colleagues wrote. “Vaccines made with live organisms, as [yellow fever vaccine] is, are supposed to be more aggressive in immunocompromised patients and are contraindicated by current guidelines. On the other hand, [yellow fever] per se is a very serious disease with high mortality rates. Studies on vaccination of immunosuppressed individuals are needed in order to solve this dilemma.” – by Marley Ghizzone

Disclosures: Grossi reports serving as a consultant for Angelini, Becton Dickinson, Biotest, Dohme, Gilead Sciences, Merck, Paratek, Sharp and Shire, and is a member of the speakers’ bureaus for Angelini, Biotest, Dohme, Gilead Sciences, Merck, Novartis, Pfizer and Sharp. Pierrotti and colleagues report no relevant financial disclosures.

Amid a yellow fever outbreak in Southeastern Brazil, an unvaccinated kidney transplant recipient contracted the disease and died, highlighting a “great dilemma” physicians must contend with — advising immunocompromised patients about vaccination in areas affected by yellow fever, researchers reported in Clinical Infectious Diseases.

In a related editorial, Paolo A. Grossi, MD, PhD, professor of infectious diseases at the University of Insubria in Varese, Italy, noted that solid organ transplant survival rates have improved over the years, making transplant surgery a “durable therapy.”

“Most [solid organ transplant] recipients show excellent survival rates and the vast majority is rehabilitated to a normal life,” he wrote. “However, lifelong immunosuppressive regimens place them at increased risk of developing opportunistic and nonopportunistic infections. Further, they are less likely to develop a robust response to vaccines for routine and travel-related pathogens and live-attenuated vaccines have been historically contraindicated in immunosuppressed [solid organ transplant] recipients.”

Grossi said transplant physicians should be aware that globalization and climate change may be having an effect on the spread of infectious diseases.

“Studies suggest that longterm climate warming tends to favor the geographic expansion of several infectious diseases and that extreme weather events may foster opportunities for more clustered disease outbreaks or outbreaks at non-traditional places and time. The recent Brazilian urban outbreak of [yellow fever] is an example of this phenomenon,” Grossi wrote. “Transplant physicians should be aware of these changes and consider that [solid organ transplant] recipients may be sentinel for new outbreaks or emerging infections.”

The patient who died was 58 years old in February 1993 when he received a kidney allograft transplant from a deceased donor. He had a good outcome, had good renal function and was maintained with azathioprine, cyclosporine and low-dose prednisone, according to the report.

In December of 2017, almost 25 years after transplantation, he was admitted to the hospital, presenting with a fever lasting 2 days, malaise, nausea and vomiting. He lived 6 kilometers from a city park that contained remains of native forest where monkeys affected by yellow fever had been detected, the researchers reported. He was clinically well upon admission, but deteriorated and died 6 days after hospital admission. RT-PCR-confirmed that he was infected with yellow fever virus — the first reported case of yellow fever in a transplant recipient, according to the report.

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Despite yellow fever being a vaccine-preventable disease, vaccination was not possible because of the patient’s immunosuppressed status.

“Vaccination may lead to viscerotropic vaccine disease, which may be fatal,” Lígia C. Pierrotti, MD, PhD, an infectious disease physician at the Hospital das Clinicas at the University of São Paulo, and colleagues wrote. “Vaccines made with live organisms, as [yellow fever vaccine] is, are supposed to be more aggressive in immunocompromised patients and are contraindicated by current guidelines. On the other hand, [yellow fever] per se is a very serious disease with high mortality rates. Studies on vaccination of immunosuppressed individuals are needed in order to solve this dilemma.” – by Marley Ghizzone

Disclosures: Grossi reports serving as a consultant for Angelini, Becton Dickinson, Biotest, Dohme, Gilead Sciences, Merck, Paratek, Sharp and Shire, and is a member of the speakers’ bureaus for Angelini, Biotest, Dohme, Gilead Sciences, Merck, Novartis, Pfizer and Sharp. Pierrotti and colleagues report no relevant financial disclosures.