Correspondence

Transmission of Histoplasmosis by Organ Transplantation

N Engl J Med 2001; 344:310January 25, 2001

Article

To the Editor:

The morbidity associated with the transmission of histoplasmosis by organ transplantation, as reported by Limaye et al. (Oct. 19 issue),1 could have been avoided by timely autopsies of the donors. We were able to avoid the transmission of disease from a donor in the case described below.

A 45-year-old woman died 12 days after spontaneous rupture of a berry aneurysm. Within 10 minutes after the procedures for organ and tissue donation had been completed, an autopsy was begun. Dozens of miliary lesions were found on the lung surfaces. These findings were immediately reported to all concerned parties, with the notification that the kidneys, pancreas, heart, and tissues were not to be used for transplantation because the lesions might represent histoplasmosis or tuberculosis. Histoplasma capsulatum was subsequently identified in some of the approximately 200 granulomas that were found. The importance of a timely autopsy of an organ donor is evident.

This case and several others led to a change of practice in our institutions. Currently, a pathologist participates in the evaluation of thoracoabdominal organs from donors by performing gross and frozen-section studies. Cooperation and rapid communication among the medical examiners, pathologists, and transplantation services can safeguard the recipients of transplants.

Billy E. Buck, M.D.
Theodore I. Malinin, M.D.
University of Miami Tissue Bank, Miami, FL 33101

Joseph H. Davis, M.D.
Miami–Dade County Medical Examiner Department, Miami, FL 33136

1 References

1. 1

   Limaye AP, Connolly PA, Sagar M, et al. Transmission of Histoplasma capsulatum by organ transplantation. N Engl J Med 2000;343:1163-1166
   Full Text | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: We agree with Buck and colleagues that close cooperation among medical examiners, pathologists, and transplantation teams is critical and that early autopsy may have prevented the transmission of H. capsulatum from the donor in the case they describe. However, in the cases we described, this approach might not have prevented transmission. In our study, no miliary lesions or other evidence of active or past H. capsulatum infection was found in the donor, yet infection was transmitted to two of three recipients of organs from that donor (both kidney recipients). Disseminated histoplasmosis developed in both patients but was successfully treated. Although the liver might be predicted to pose the greatest risk for transmission, serologic or clinical evidence of infection never developed in the recipient of the liver transplant.

Since the factors that predict the transmission of H. capsulatum by transplantation are unknown, the approach advocated by Buck and colleagues could lead to unnecessary disposal of scarce organs on the basis of a theoretical risk that a potentially treatable infectious agent could be transmitted. In addition, logistic difficulties, increased expense, and the probable low yield (at least with regard to infectious agents)1,2 make this approach difficult to recommend.

We favor a system of early notification about any potential allograft-transmitted infections. Although such a system is an after-the-fact approach, it could be readily implemented with the use of the current organ-procurement infrastructure, and would provide a means of recognizing and tracing transplant-transmitted infections. Any clinician who suspected an allograft-transmitted infection would report the suspicion to the local organ-procurement agency, which would then notify the health care providers for all other recipients of organs or tissue from the same donor. Depending on the clinical circumstances and the specific infectious agent involved, close monitoring, further diagnostic testing, or even empirical therapy could then be used as appropriate. Until there are additional data demonstrating the benefits of routine autopsy for preventing transplant-transmitted infections, a system of voluntary reporting and tracing of possible transplant-transmitted infections, as we have outlined, may be a reasonable approach.

Ajit P. Limaye, M.D.
Manish Sagar, M.D.
University of Washington School of Medicine, Seattle, WA 98195-7110

2 References

1. 1

   Burgess BL, Roberts P, Boguski J, Lovell D, Chase DC, Goldman MH. Occult disease in tissue and organ donors -- a case for routine autopsy. Transplantation 1994;58:734-735
   Web of Science | Medline

2. 2

   Otero J, Fresno MF, Escudero D, Seco M, Gonzalez M, Peces R. Detection of occult disease in tissue donors by routine autopsy. Transpl Int 1998;11:152-154
   CrossRef | Web of Science | Medline

Citing Articles (3)

Citing Articles

1. 1

   Steven E. Weinberger, Barbara A. Cockrill, Jess Mandel. 2008. Miscellaneous Infections Caused by Fungi and Pneumocystis. , 317-327.
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2. 2

   Melissa D. Johnson, John R. Perfect. (2007) Fungal infections of the bones and joints. Current Infectious Disease Reports 3:5, 450-460
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3. 3

   Melissa D. Johnson, John R. Perfect. (2001) Fungal infections of the bones and joints. Current Infectious Disease Reports 3:5, 450-460
   CrossRef