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How Lifesaving Transplants Turned Deadly

Review of rabies case in Texas last year highlights challenges of organ donation

THURSDAY, March 17, 2005 (HealthDay News) -- Almost a year after rabies turned potentially lifesaving organ transplants into a death sentence for four people, scientists are evaluating what went wrong and what could be done to improve the system.

The story itself was startling: In early May of 2004, an apparently healthy man arrived at Christus St. Michael Hospital in Texarkana, Texas, with "altered mental status," a fever and fluctuating blood pressures. Neurological imaging revealed a brain hemorrhage, and the man died 48 hours later.

No one had any idea that the man had rabies, apparently contracted after he was bitten by a bat. As a result, his organs were screened for a host of infectious agents and then they were donated. The organs were not, however, screened for rabies, because it is so rare in humans. Only two human cases were reported in the United States in 2003, and there have been no more than six cases in any year during the past decade.

The man's liver, two kidneys and a piece of an artery were then transplanted into four different people. All four died in early June. A fifth recipient, slated to receive a lung, died on the operating table.

This was the first time that rabies had been spread through solid organ transplantation, although the virus has been transmitted through corneal transplants in the past. Last month, however, two transplant patients in Germany died after receiving organs from a woman infected with the rabies virus.

The Texas case points up the constantly evolving challenges of organ and vessel transplantation, according to the authors of an article appearing in the March 17 issue of the New England Journal of Medicine.

This particular case was riddled with both fortunate and unfortunate coincidences.

Upon arrival at the hospital, the donor had tested positive for cocaine and marijuana. "Cocaine can cause blood pressure elevations, and the very high blood pressure can then be associated with subarachnoid hemorrhage," said Dr. Arjun Srinivasan, lead author of the article and a medical epidemiologist with the U.S. Centers for Disease Control and Prevention in Atlanta. "That complicated the picture."

In retrospect, however, the man's symptoms were consistent with rabies.

On the other hand, all of the recipients underwent their procedures at the same facility, Baylor University Medical Center, which made tracking easier. A similar situation had aided an investigation into the outbreak of West Nile virus through organ transplantation, Srinivasan said.

"One of the difficulties in organ and tissue transplantation is that there are multiple agencies involved," explained Michael Strong, executive vice president of the Puget Sound Blood Center/Northwest Tissue Center in Seattle. "Fortunately, or unfortunately in this particular case, all of the organs and tissues were transplanted at the same place, so they had a quick ability to diagnose the cases and to do the detective work to pin it down."

According to Srinivasan, no other tissues had been taken from the donor.

Certainly, the episode highlights a need for health-care providers to be more aware of rabies. "Rabies is a very unusual disease, but it does occur in this country," Srinivasan said. "When you have unexplained encephalitis [brain infection], rabies is on the list."

But improvements also need to take on a broader dimension, Srinivasan stressed.

"Yes, we can talk about adding rabies screening, but the bigger question is, how do you work on the entire system to use this experience to optimize the safety of organ and tissue transplants?" he said.

One way would be through better tracking. "Obviously, when a vessel segment is procured with organs, there should be very meticulous records as to where that vessel segment is, used or destroyed," Srinivasan said.

Right now, records are not standardized, but left up to individual institutions.

"Many blood banks in hospitals are now being given the assignment of managing this tracing and tracking ability for organs and tissues," Strong said. "That makes some sense because blood banks are accustomed to traceability and have good record-keeping management."

There's also an issue of communication.

"Five organs can go to five different states," Srinivasan stated. "There needs to be a way to improve communication across state lines."

For experts involved in organ transplantation, the litany of possible problems is a long one and getting longer. "It's a huge list," Srinivasan said.

More information

The U.S. Centers for Disease Control and Prevention has more on rabies.

SOURCES: Arjun Srinivasan, M.D., medical epidemiologist, U.S. Centers for Disease Control and Prevention, Atlanta; Michael Strong, Ph.D., executive vice president, Puget Sound Blood Center/Northwest Tissue Center, Seattle; March 17, 2005, New England Journal of Medicine
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