Rabies caused encephalitis that killed four transplant recipients within 50 days of receiving organs from a common donor, the Centers for Disease Control and Prevention has reported.
Only during the postmortem investigations was it discovered that a bat had bitten the male donor before he died, said Arjun Srinivasan, M.D., and his associates (N. Engl. J. Med. 2005;352:1103–11).
Four days before dying, the donor was seen twice in an emergency department for nausea, vomiting, and difficulty swallowing. He was then admitted to another hospital with altered mental status requiring intubation, fever of 100.5° F, and systolic blood pressure more than 200 mm Hg.
A toxicology screen was positive for cocaine and marijuana. Imaging showed an ongoing subarachnoid hemorrhage that eventually led to seizures, coma, and brain death.
No donor screening tests had indicated any danger of infectious disease.
Two patients each received one kidney, and a third received the liver. Within 30 days, all developed progressive encephalitis with rapid neurologic deterioration (agitated delirium and seizures) followed by respiratory failure within 48 hours. Death followed 7–23 days after onset of neurologic symptoms.
CNS tissue specimens obtained at autopsy showed characteristic signs of rabies—Negri bodies, particularly in the Purkinje cells of the cerebellum and neurons in the frontal cortex, thalamus, hippocampus, midbrain, and pons.
Suckling mice inoculated with cultures of tissue suspension and cerebrospinal fluid died or developed neurologic abnormalities within 7–10 days.
Furthermore, a fourth patient, who had received an iliac artery graft from the infected donor to revise the hepatic artery after liver transplantation, also died from encephalitis.
Symptoms of rabies typically don't develop this quickly, the investigators noted. “It is unknown whether the shorter incubation period was due to the immunosuppression, the route of transmission, or both.”
Michele G. Sullivan