Successful prevention of syphilis transmission from a multiple organ donor with serological evidence of syphilis

Sexually transmitted infections and female reproductive health

Women are disproportionately affected by sexually transmitted infections (STIs) throughout life. In addition to their high prevalence in women, STIs have debilitating effects on female reproductive health due to female urogenital anatomy, socio-cultural and economic factors. In this Review, we discuss the prevalence and impact of non-HIV bacterial, viral and parasitic STIs on the reproductive and sexual health of cisgender women worldwide. We analyse factors affecting STI prevalence among transgender women and women in low-income settings, and describe the specific challenges and barriers to improved sexual health faced by these population groups. We also synthesize the latest advances in diagnosis, treatment and prevention of STIs.

Women are more affected by sexually transmitted infections than men. This Review examines the impact of non-HIV STIs on women’s health, and discusses recent advances and current challenges in the treatment and prevention of STIs.

Secondary syphilis with liver involvement in a liver transplant recipient

Syphilis is capable of compromising almost any organ; however, syphilitic hepatitis is a rare manifestation that has been described most often in HIV-infected patients. Herein, we present a 33-year-old male liver transplant recipient who presented with progressive liver dysfunction characterized by mild ALT elevation and rising cholestasis, malaise, skin rash, and alopecia. Skin biopsy was characteristic of secondary syphilis, confirmed by both skin and liver biopsy-positive immunohistochemical staining for Treponema pallidum. The patient was treated with benzathine penicillin G 2.4 million units IM q week × 3 weeks. Three months later, the patient was asymptomatic and recovered from his general malaise. He showed no skin lesions and demonstrated complete regrowth of the hair on his scalp, beard, and eyebrows. The presence of liver dysfunction with cholestasis in a transplant recipient should alert transplant providers to the possibility of syphilitic hepatitis, particularly in men who have sex with men. Though not an early manifestation, cutaneous signs of secondary syphilis may be a helpful diagnostic indicator in most cases.

Infectious Disease Transmission in Solid Organ Transplantation: Donor Evaluation, Recipient Risk, and Outcomes of Transmission

In 2016, the Transplantation Society of Australia and New Zealand, with the support of the Australian Government Organ and Tissue authority, commissioned a literature review on the topic of infectious disease transmission from deceased donors to recipients of solid organ transplants. The purpose of this review was to synthesize evidence on transmission risks, diagnostic test characteristics, and recipient management to inform best-practice clinical guidelines. The final review, presented as a special supplement in Transplantation Direct, collates case reports of transmission events and other peer-reviewed literature, and summarizes current (as of June 2017) international guidelines on donor screening and recipient management. Of particular interest at the time of writing was how to maximize utilization of donors at increased risk for transmission of human immunodeficiency virus, hepatitis C virus, and hepatitis B virus, given the recent developments, including the availability of direct-acting antivirals for hepatitis C virus and improvements in donor screening technologies. The review also covers emerging risks associated with recent epidemics (eg, Zika virus) and the risk of transmission of nonendemic pathogens related to donor travel history or country of origin. Lastly, the implications for recipient consent of expanded utilization of donors at increased risk of blood-borne viral disease transmission are considered.

Donor-Derived Infections: Incidence, Prevention, and Management

Organ donors reflect the diverse US population, and there are an increasing number of donors born in, who have resided in, or who have traveled to underdeveloped areas of the world or areas with geographically restricted infections. As such, these donors are exposed to pathogens that can potentially be transmitted to recipients of the donor’s organs. Additionally, there are newer techniques to identify many pathogens that may be transmitted from the donor to the transplant recipients. Finally, high-profile reports of several donor-derived infections have heightened awareness of donor-derived infections and have likely contributed to increased recognition. In this chapter, the incidence, methods of identification and prevention, and management of unexpected donor-derived infections will be reviewed.

Improving syphilis screening in deceased organ donors

BACKGROUND

Current U.S. policy requires screening of all deceased organ donors for syphilis infection. To date, information on syphilis test performance in this population is limited.

METHODS

All donors with a positive rapid plasma reagin (RPR) and matched donors with negative RPR who were evaluated by one organ procurement organization from January 1, 2000, to September 30, 2012, were retrospectively tested, using retained, residual serum, with two alternate RPR tests and four treponemal-specific tests: A fluorescent treponemal antibody absorption test, a microhemagglutination test, a chemiluminescence immunoassay (CLIA), and a Treponema pallidum particle agglutination (TP-PA) test.

RESULTS

Thirty-two of 3,555 (0.9%) potential deceased organ donors screened during the study period showed a positive RPR; 61 RPR-negative matched donor samples were studied as well. Thirteen (40.6%) of the RPR-positive donors were found to be false-positive based on confirmatory TP-PA. As compared to TP-PA, the sensitivity of the fluorescent treponemal antibody absorption, microhemagglutination, and CLIA was 87.5%, 91.7% and 100%, respectively. The CLIA and TP-PA results were 100% concordant. Only 17 (53.1%) of the RPR-positive donors had a total of 46 organs recovered for transplantation.

CONCLUSION

Current screening of deceased organ donors by RPR yields a significant number of false-positive results. Use of alternative tests or the routine use of confirmatory tests may reduce the frequency of false-positive results in deceased organ donors.

Syphilis transmission: a review of the current evidence

Syphilis remains widespread worldwide, with increasing rates among men who have sex with men. This paper reviews available evidence regarding syphilis transmission, including data on: sexual transmission (transmission probability per sexual partnership), vertical transmission, transmission via blood products and organ donation, and other rare modes of transmission. In addition, host susceptibility to syphilis infection is discussed. Syphilis screening and treatment, condoms and risk-reduction counselling and how they modify syphilis transmission dynamics are considered.

A syphilis-positive organ donor -- management of the cardiac transplant recipient: a case report and review of the literature

Syphilis as a public health problem has not been resolved. Because donor organs are scarce, Treponema pallidum seropositivity is no longer considered a contraindication to transplant. However, there is little guidance on the management and monitoring on the recipient of organs from patients with syphilis. We present a case of a patient successfully transplanted with a heart from a seropositive donor and a review of the literature.

[Evaluation of the potential organ donor with special regards to heart donation]

Angesichts der auch in Österreich vorherrschenden Knappheit an verfügbaren Organspendern für Herztransplantationen erscheint es dringlich notwendig, eine Optimierung von Spenderevaluierung und Management zu diskutieren. In der vorliegenden Arbeit werden allgemeine Spenderkriterien und herzspezifische Parameter detailliert diskutiert und im Zusammenhang mit der internationalen Literatur dargestellt. Es wird der "marginale" und im Gegensatz dazu der "optimale" Organspender definiert. Das Spendermanagement wird besprochen, wobei neben der hämodynamischen Optimierung auch auf zusätzliche intensivmedizinische Aspekte eingegangen wird. Erst die exakte Evaluierung erlaubt die individuelle Zuteilung des Organs zum passenden Empfänger und stellt somit insbesondere bei marginalen Spendern die Grundlage eines Therapieerfolgs dar.

Syphilis-specific immunoglobulin G seroconversion after double-lung transplantation

A female patient with end-stage chronic obstructive pulmonary disease received a double-lung transplant from a donor with serologic evidence of past syphilis. The recipient showed a Treponema pallidum-specific IgG seroconversion 8 days after transplantation with increasing titers at follow-up. In Month 3 post-transplantation the immunoglobulin G (IgG) antibody titer decreased. Retrospectively, we argue that the reactive syphilis serology in the recipient was due to a transmission of immunocompetent B cells in the graft rather than a transmission of T pallidum.

Hépatite à syphilis et transplantation hépatique

We report a case of secondary syphilis hepatitis in a liver-transplant patient. This homosexual male patient presented, 15 years after orthotopic liver transplantation, with non-squamous papulomacular rash, mild cytolysis, and anicteric cholestasis. Laboratory tests showed syphilis seroconversion with a venereal diseases research laboratory (VDRL) titer of 1/256, a Treponema pallidum hemaglutination assay (TPHA) of 1/5120, and a positive IgM fluorescent Treponemal antibody absorbance (FTA-abs). A liver biopsy performed 13 months after the diagnosis showed low-grade hepatitis with a Metavir score of A1F1; it also showed non-specific portal moderate inflammation consisting primarily of neutrophils, with no evidence of cholestasis. He was given benzathine-penicillin at 2,400,000 IU with a transient increase in prednisolone doses. Cytolysis rapidly, and cholestasis progressively disappeared. IgM FTA-abs became negative, whereas VDRL and TPHA titers decreased slightly over time.

Secondary syphilis after liver transplantation: case report and review of the literature

Syphilitic disease is uncommon, but its incidence has increased worldwide in the last few years. An unusual manifestation of secondary syphilis after orthotopic liver transplantation is described which confirms that lues should be considered in patients with immune deficiency and abnormal liver function tests.

Successful Heterotopic Heart Transplant After Cardiopulmonary Bypass Rescue of an Arrested Donor Heart

Global heart transplantation has declined due to the donor shortage. The use of marginal donors has therefore been reintroduced. According to the history of heart transplantation, heterotopic heart transplant has played an important role in the precyclosporine era. In those circumstances, native heart and donor heart worked together to support each other against rejection or progressive heart failure. However, heterotopic transplantation has complicated surgical techniques and requirements for postoperative surveillance. Most training fellows have limited experience with this approach. At present more than 1000 cardiac surgical centers perform heart transplantation, but only 50 centers have experience in performing-heterotopic procedures. Using mechanical circulatory support for the posttransplant period is well developed in most centers. However, using mechanical circulatory support for heart donor with the intention of rescuing the heart has not been reported. Herein, we report a successful heterotopic heart transplantation after rescue with cardiopulmonary bypass of an arrested donor heart.

Late Syphilis in a Cardiac Transplant Patient

Patients undergoing cardiac transplantation are routinely screened for prior exposure to Treponema pallidum, the bacterium implicated in syphilis. Although acute syphilis typically presents with a painless genital chancre, chronic syphilis can manifest in protean forms and linger undiagnosed. Left untreated, syphilis can cause multi-system disease, particularly irreversible neurologic damage. We describe a case of cutaneous secondary syphilis, neurosyphilis and luetic hepatitis in a cardiac transplant patient.

A Report of the Amsterdam Forum On the Care of the Live Kidney Donor: Data and Medical Guidelines

Kidney transplant physicians and surgeons met in Amsterdam, The Netherlands, from April 1-4, 2004 for the International Forum on the Care of the Live Kidney Donor. Forum participants included over 100 experts and leaders in transplantation representing more than 40 countries from around the world, including participants from the following continents: Africa, Asia, Australia, Europe, North America, and South America.

Orthotopic liver transplantation from a donor with a history of schistosomiasis

The shortage of liver donors and the increasing number of patients on the waiting list for liver transplantation have led to a widening of the definition of suitable liver donors. In this case report, we describe transplantation of a liver from a 20-year-old brain-dead donor with a past history of schistosomiasis. Careful evaluation for schistosomiasis-related hepatic complications using hepatic function tests, clinical assessment for manifestations of portal hypertension, as well as abdominal ultrasound, and liver biopsy were performed. At 7 months follow-up, the recipient is doing well with normal liver function. Liver transplantation from a donor with a history of schistosomiasis is acceptable in carefully screened cases.

Extended criteria for organ acceptance. Strategies for achieving organ safety and for increasing organ pool

The terms extended donor or expanded donor mean changes in donor acceptability criteria. In almost all cases, the negative connotations of these terms cannot be justified. Factors considered to affect donor or organ acceptability have changed with time, after showing that they did not negatively affect graft or patient survival per se or when the adequate measures had been adopted. There is no age limit to be an organ donor. Kidney and liver transplantation from donors older than 65 years can have excellent graft and patient actuarial survival and graft function. Using these donors can be from an epidemiological point of view the most important factor to esablish the final number of cadaveric liver and kidney transplantations. Organs with broad structural parenchyma lesion with preserved functional reserve and organs with reversible functional impairment can be safely transplanted. Bacterial and fungal donor infection with the adequate antibiotic treatment of donor and/or recipient prevents infection in the latter. The organs, including the liver, from donors with infection by the hepatitis B and C viruses can be safely transplanted to recipients with infection by the same viruses, respectively. Poisoned donors and non-heart-beating donors, grafts from transplant recipients, reuse of grafts, domino transplant and splitting of one liver for two recipients can be an important and safe source of organs for transplantation.

Cardiac Transplantation: Pre-transplant Infectious Diseases Evaluation and Post-transplant Prophylaxis

Screening of recipients and donors of cardiac allografts for infectious pathogens, and the use of appropriate immunization and antimicrobial prophylaxis strategies, remain important for the control of infection following heart transplantation. However, the risk of infectious complications in a particular patient must often be weighed against the risk of delaying or denying allograft transplantation. In addition, the ongoing degree of immunosuppression and its contribution to the risk for infectious complications should also be considered to guide the length of prophylactic antimicrobial therapy and provide optimal patient care.