Transmission of rabies virus from an organ donor to four transplant recipients

Susceptibility of solid organ transplant recipients to viral pathogens with zoonotic potential: A mini-review

A substantial number of zoonotic diseases are caused by viral pathogens, representing a significant menace to public health, particularly to susceptible populations, such as pregnant women, the elderly, and immunocompromised individuals. Individuals who have undergone solid organ transplantation frequently experience immunosuppression, to prevent organ rejection, and, thus are more prone to opportunistic infections. Furthermore, the reactivation of dormant viruses can threaten transplant recipients and organ viability. This mini-review examines the up-to-date literature covering potential zoonotic and organ rejection-relevant viruses in solid organ transplant recipients. A comprehensive list of viruses with zoonotic potential is highlighted and the most important clinical outcomes in patients undergoing transplantation are described. Moreover, this mini-review calls attention to complex multifactorial events predisposing viral coinfections and the need for continuous health surveillance and research to understand better viral pathogens' transmission and pathophysiology dynamics in transplanted individuals.

Viral meningoencephalitis in pediatric solid organ or hematopoietic cell transplant recipients: a diagnostic and therapeutic approach

Neurologic complications, both infectious and non-infectious, are frequent among hematopoietic cell transplant (HCT) and solid organ transplant (SOT) recipients. Up to 46% of HCT and 50% of SOT recipients experience a neurological complication, including cerebrovascular accidents, drug toxicities, as well as infections. Defects in innate, adaptive, and humoral immune function among transplant recipients predispose to opportunistic infections, including central nervous system (CNS) disease. CNS infections remain uncommon overall amongst HCT and SOT recipients, compromising approximately 1% of total cases among adult patients. Given the relatively lower number of pediatric transplant recipients, the incidence of CNS disease amongst in this population remains unknown. Although infections comprise a small percentage of the neurological complications that occur post-transplant, the associated morbidity and mortality in an immunosuppressed state makes it imperative to promptly evaluate and aggressively treat a pediatric transplant patient with suspicion for viral meningoencephalitis. This manuscript guides the reader through a broad infectious and non-infectious diagnostic differential in a transplant recipient presenting with altered mentation and fever and thereafter, elaborates on diagnostics and management of viral meningoencephalitis. Hypothetical SOT and HCT patient cases have also been constructed to illustrate the diagnostic and management process in select viral etiologies. Given the unique risk for various opportunistic viral infections resulting in CNS disease among transplant recipients, the manuscript will provide a contemporary review of the epidemiology, risk factors, diagnosis, and management of viral meningoencephalitis in these patients.

Transcriptome analysis of salivary glands of rabies-virus-infected mice

Rabies is a fatal zoonotic disease that poses a threat to public health. Rabies virus (RABV) is excreted in the saliva of infected animals, and is primarily transmitted by bite. The role of the salivary glands in virus propagation is significant, but has been less studied in the pathogenic mechanisms of RABV. To identify functionally important genes in the salivary glands, we used RNA sequencing (RNA-seq) to establish and analyze mRNA expression profiles in parotid tissue infected with two RABV strains, CVS-11 and PB4. The biological functions of differentially expressed genes (DEGs) were determined by Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis, which revealed 3,764 DEGs (678 up-regulated and 3,086 down-regulated) in the CVS-11 infected group and 4,557 DEGs (874 up-regulated and 3,683 down-regulated) in the PB4 infected group. Various biological processes are involved, including the salivary secretion pathway and the phosphatidylinositol 3-kinase-Akt (PI3K-Akt) signaling pathway. This study provides the first mapping of the transcriptome changes in response to RABV infection in parotid tissue, offering new insights into the study of RABV-affected salivary gland function and RABV pathogenic mechanisms in parotid tissue. The salivary gland-enriched transcripts may be potential targets of interest for rabies disease control.

Neuroimmunology of rabies: New insights into an ancient disease

Rabies is an ancient neuroinvasive viral (genus Lyssavirus, family Rhabdoviridae) disease affecting approximately 59,000 people worldwide. The central nervous system (CNS) is targeted, and rabies has a case fatality rate of almost 100% in humans and animals. Rabies is entirely preventable through proper vaccination, and thus, the highest incidence is typically observed in developing countries, mainly in Africa and Asia. However, there are still cases in European countries and the United States. Recently, demographic, increasing income levels, and the coronavirus disease 2019 (COVID-19) pandemic have caused a massive raising in the animal population, enhancing the need for preventive measures (e.g., vaccination, surveillance, and animal control programs), postexposure prophylaxis, and a better understanding of rabies pathophysiology to identify therapeutic targets, since there is no effective treatment after the onset of clinical manifestations. Here, we review the neuroimmune biology and mechanisms of rabies. Its pathogenesis involves a complex and poorly understood modulation of immune and brain functions associated with metabolic, synaptic, and neuronal impairments, resulting in fatal outcomes without significant histopathological lesions in the CNS. In this context, the neuroimmunological and neurochemical aspects of excitatory/inhibitory signaling (e.g., GABA/glutamate crosstalk) are likely related to the clinical manifestations of rabies infection. Uncovering new links between immunopathological mechanisms and neurochemical imbalance will be essential to identify novel potential therapeutic targets to reduce rabies morbidity and mortality.

Rabies in a postpandemic world: resilient reservoirs, redoubtable riposte, recurrent roadblocks, and resolute recidivism

Rabies is an ancient disease. Two centuries since Pasteur, fundamental progress occurred in virology, vaccinology, and diagnostics-and an understanding of pathobiology and epizootiology of rabies in testament to One Health-before common terminological coinage. Prevention, control, selective elimination, and even the unthinkable-occasional treatment-of this zoonosis dawned by the twenty-first century. However, in contrast to smallpox and rinderpest, eradication is a wishful misnomer applied to rabies, particularly post-COVID-19 pandemic. Reasons are minion. Polyhostality encompasses bats and mesocarnivores, but other mammals represent a diverse spectrum of potential hosts. While rabies virus is the classical member of the genus, other species of lyssaviruses also cause the disease. Some reservoirs remain cryptic. Although global, this viral encephalitis is untreatable and often ignored. As with other neglected diseases, laboratory-based surveillance falls short of the notifiable ideal, especially in lower- and middle-income countries. Calculation of actual burden defaults to a flux within broad health economic models. Competing priorities, lack of defined, long-term international donors, and shrinking local champions challenge human prophylaxis and mass dog vaccination toward targets of 2030 for even canine rabies impacts. For prevention, all licensed vaccines are delivered to the individual, whether parenteral or oral-essentially 'one and done'. Exploiting mammalian social behaviors, future 'spreadable vaccines' might increase the proportion of immunized hosts per unit effort. However, the release of replication-competent, genetically modified organisms selectively engineered to spread intentionally throughout a population raises significant biological, ethical, and regulatory issues in need of broader, transdisciplinary discourse. How this rather curious idea will evolve toward actual unconventional prevention, control, or elimination in the near term remains debatable. In the interim, more precise terminology and realistic expectations serve as the norm for diverse, collective constituents to maintain progress in the field.

Canine rabies: An epidemiological significance, pathogenesis, diagnosis, prevention, and public health issues

Rabies is a zoonotic disease caused by rabies virus of the genus Lyssa virus and family Rhabdoviridae. It affects all mammals and is prevalent throughout the world and endemic in many countries except in Islands like Australia and Antarctica. It is highly fatal, but preventable. Disease causes threat to public health because rabid dogs bite humans, resulting in thousands of deaths every year. Around 59,000 people die every year from rabies in the world. Dogs play a vital role in most of the human exposure in rabies endemic areas. Transmission of virus occurs through the bite of an infected dog. Disease is manifested by fatal nervous symptoms leading to paralysis and death. Direct fluorescent antibody technique is the gold standard for the diagnosis of the disease in animals and humans. Prevention of rabies involves the vaccination of dogs and humans before or after an exposure. This review describes the etiology, pathogenesis, diagnosis, its prevention and control strategies.

Successful use of venous graft from native liver with hepatocellular carcinoma during living donor liver transplantation with no impact on recurrence rate: A retrospective cohort study

Introduction

There are still debates regarding using portal vein (PV) from liver with hepatocellular carcinoma (HCC) for vascular reconstruction. This study aimed to assess the feasibility and patency of PV venous graft from an explanted liver with HCC for the reconstruction of the hepatic veins tributaries or PV in living donor liver transplantation (LDLT) and to see if it has any risk on recurrence of HCC.

Patient and methods

We conducted a retrospective study on 81 patients with HCC who underwent LDLT from April 2004 to July 2022.

Results

Venous graft from native liver PV was used for vascular reconstruction in 31 patients as follows; reconstruction of V5 in 7 patients, V8 in 4 patients, V6 in 3 patients, combined V5 and V8 in 4 patients, V6 with V5/V8 in 5 patients, and as Y shape venous graft for 2 PV reconstruction in 8 patients. The implantation of the new conduit PV graft after reconstruction of the anterior sector tributaries was direct to the IVC in 8 patients, and to the common orifice of the left and middle hepatic veins in 12 patients. The 1 month, 3 months, and 1-year overall patency of the venous graft was 93.5%, 90.3%, and 84%, respectively. Nine patients had recurrent HCC. In multivariate analysis, the independent risk factors for HCC recurrence were AFP >400 ng/mL (HR = 1.47, 95% CI: 1.69–2.31, P = 0.01), moderate/poor differentiated tumor (HR = 3.06, 95% CI: 2.58–6.29, P = 0.02), and microvascular invasion (HR = 2.51, 95% CI: 1.05–1.93, P = 0.01). Using a PV venous graft had no risk factor for HCC recurrence (P = 0.9).

Conclusion

The use of PV venous graft of native liver with HCC for venous reconstruction is a feasible and valuable option in LDLT with good patency rates and no risk of HCC recurrence.

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The use of PV venous graft of native liver with HCC for venous reconstruction is a feasible and valuable option in LDLT.

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It has good patency rates and no risk on HCC recurrence.

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The independent risk factors for HCC recurrence in our study were AFP >400 ng/mL, moderate/poor differentiated tumor, and microvascular invasion.

Establishment and clinical validation of an in-cell-ELISA-based assay for the rapid quantification of Rabies lyssavirus neutralizing antibodies

Neutralizing antibodies (nAbs) prevent the entry of viruses into permissive cells. Since nAbs represent correlates of protection against the Rabies lyssavirus, the presence of sufficient nAbs indicates effective vaccination. Accordingly, Rabies lyssavirus-specific nAb titers need to be determined in routine diagnostics to identify individuals being at risk of Rabies lyssavirus infections due to insufficient immunity. The current gold standard for the quantification of Rabies lyssavirus-specific nAbs is the rapid fluorescent focus inhibition test (RFFIT). However, RFFITs are expensive and labor-intensive since multiple microplate wells must be evaluated one-by-one by trained personnel through microscopic inspection, which limits the number of samples that can be processed. To overcome this disadvantage, we established a novel assay for Rabies lyssavirus-specific nAbs relying on an in-cell-ELISA (icELISA)-based neutralization test (icNT). The icNT differs from the RFFIT in the readout phase, and can be automatically quantified in minutes using broadly available microplate readers. During the establishment, icNT parameters such as antibody concentrations, permeabilization procedures, blocking reagents, infectious doses, and the duration of infection were optimized. Afterwards, a dose-dependent detection of Rabies lyssavirus neutralization was demonstrated using the WHO Standard Rabies Immunoglobulin reference. A panel of 200 sera with known RFFIT titers revealed very good sensitivity and specificity of the icNT. Furthermore, the icNT showed very good intra- and inter-assay precision. By recognizing Rabies lyssavirus-specific antigens, the assay can be applied immediately to automatically quantify the concentration of Rabies lyssavirus nAbs in routine diagnostics or for various basic research questions such as screening for antiviral compounds.

Magnetic resonance imaging abnormalities in encephalomyelitis due to paralytic rabies: A case report

The diagnosis of rabies, a potentially fatal neuroinfectious disease, should be strongly considered in all patients who develop encephalitis following an infected animal bite even when they have received post-exposure prophylaxis. In the absence of confirmatory tests, typical magnetic resonance imaging findings help confirm the clinical diagnosis of rabies.

Eliminating dog-mediated rabies: challenges and strategies

Rabies is an acute encephalitis caused by a lyssavirus. It is primarily transmitted through bites of infected dogs which results in the worldwide death of an estimated 59000 humans every year. The disease is preventable through the application of post-exposure prophylaxis (PEP) and its elimination has been demonstrated in many countries by applying multiple interventions simultaneously. Nonetheless, rabies is still widespread in many developing countries, primarily due to the poor implementation of intervention strategies that include inadequate dog-bite wound management practices, unavailability/unaffordability of PEP by the communities, failure to control the disease in free-roaming dogs and wildlife, improper dog population management, weak surveillance and diagnostic facilities and a lack of a One Health approach to the disease. In this review, strategies to control dog-mediated rabies through a One Health approach were discussed. We recommend applying multiple interventions against the disease by involving all the concerned stakeholders in selected urban and rural areas of the countries where rabies is endemic. An empirical demonstration of disease freedom in the selected areas through a One Health approach is needed to convince policymakers to invest in rabies prevention and control on the national level. This multifaceted One Health control model will enhance the likelihood of achieving the goal of global rabies eradication by 2030.

Exploring rabies endemicity in Pakistan: Major constraints & possible solutions

Rabies, the oldest recorded viral zoonosis in the Indo-Pakistan subcontinent, is a neglected and lingering endemic disease in Pakistan. The review of online available rabies-related journals, papers and reports through platforms and electronic databases have provided the basis for a detailed analysis of the rabies situation in Pakistan. Only published materials related to various research areas of rabies in Pakistan were included and meaningful conclusions were developed to identify major constraints and generate an intellectual discussion on possible solutions. Results revealed 52 studies representing major issues concerning rabies prevention related to topics including, but not limited to: epidemiological investigations (40.38%), prophylactic measures (21.15%), population of wandering dogs (13.46%), public awareness and government interventions (17.30%) and diagnostic surveillance (7.69%). In order to minimize these problems and reduce the prevalence of dog bites or rabies in significant manners, the country direly needs to apply the following actions: a maintained supply of rabies prophylactic measures in public hospitals at subsidized rates, mass dog vaccination at regional levels, enforced responsible animal ownerships, implementing a systematic One Health approach, and diagnostic labs equipped with surveillance mechanisms established in coordination with the livestock and medical departments. This review, which presents up-to-date information on the risk factors and epidemiological features of rabies in Pakistan, provides useful information for scientists, policy makers, and administrative health officials wishing to understand how this deadly disease persists in the absence of effective control measures.

Rabies virus in slaughtered dogs for meat consumption in Ghana: A potential risk for rabies transmission

Dog-mediated rabies is responsible for approximately 60,000 human deaths annually worldwide. Although dog slaughter for human consumption and its potential risk for rabies transmission has been reported, mainly in some parts of Western Africa and South-East Asia, more information on this and factors that influence dog meat consumption is required for a better understanding from places like Ghana where the practice is common. We tested 144 brain tissues from apparently healthy dogs slaughtered for human consumption for the presence of rabies viruses using a Lyssavirus-specific real-Time RT-PCR. Positive samples were confirmed by virus genome sequencing. We also administered questionnaires to 541 dog owners from three regions in Ghana and evaluated factors that could influence dog meat consumption. We interacted with butchers and observed slaughtering and meat preparation procedures. Three out of 144 (2.1%) brain tissues from apparently healthy dogs tested positive for rabies virus RNA. Two of the viruses with complete genomes were distinct from one another, but both belonged to the Africa 2 lineage. The third virus with a partial genome fragment had high sequence identity to the other two and also belonged to the Africa 2 lineage. Almost half of the study participants practiced dog consumption [49% (265/541)]. Males were almost twice (cOR = 1.72, 95% CI (1.17-2.52), p-value = .006) as likely to consume dog meat compared to females. Likewise, the Frafra tribe from northern Ghana [cOR = 825.1, 95% CI (185.3-3672.9), p-value < .0001] and those with non-specific tribes [cOR = 47.05, 95% CI (10.18-217.41), p-value < .0001] presented with higher odds of dog consumption compared to Ewes. The butchers used bare hands in meat preparation. This study demonstrates the presence of rabies virus RNA in apparently healthy dogs slaughtered for human consumption in Ghana and suggests a potential risk for rabies transmission. Veterinary departments and local assemblies are recommended to monitor and regulate this practice.

Rabies in Europe: An epidemiological and clinical update

Rabies is a vaccine preventable zoonotic disease with a significant mortality burden worldwide. Several years of vaccination campaigns in wildlife animals have now achieved the control of rabies in Western Europe through a vaccination belt in front of endemic Eastern European countries. Nevertheless, rabies could be imported both by travellers from areas without an active public control of the disease or by animals coming from areas where the virus circulates in wildlife fauna. The knowledge of the current world epidemiology combined with a high index of clinical suspicion are needed to reach a diagnosis of rabies, especially in case of atypical presentation or without a history of animal exposure. The pre-travel counselling to people visiting highly endemic areas is essential to give information on how to reduce exposure to potential sources of infection and to select those subjects who could benefit from pre-travel vaccination. Rabies is almost invariably fatal, but the prompt administration of a vaccine course combined with anti-rabies immunoglobulins significantly reduces the probability to develop life-threatening consequences. In this review, we give a brief epidemiological and clinical update about rabies in Europe.

Rabies: Presentation, case management and therapy

Several Lyssaviruses are known to be a causative agent of rabies and rabies like syndrome. There are no proven effective treatment strategies for symptomatic rabies patient. Risk of infection from dog variant of rabies virus is highest with deep bite reaching muscular layer and much higher when compared to scratch. Failure of viral eradication at the central nervous system (CNS) is partly due to inadequate immune response. Favipiravir selectively inhibit viral RNA polymerase and has been shown to reduce rabies replication in neuronal cell and mouse model system. Endocannabinoid system has emerged as an important regulator for CNS integrity, cell fate and may serve as an important novel neuroprotective agent. Cannabinoid may be able to regulate the impaired homeostasis induced by rabies virus by promoting infected cell survival and promote complete autophagy in infected cell.

Ten years of donor-derived disease: A report of the disease transmission advisory committee

Despite clinical and laboratory screening of potential donors for transmissible disease, unexpected transmission of disease from donor to recipient remains an inherent risk of organ transplantation. The Disease Transmission Advisory Committee (DTAC) was created to review and classify reports of potential disease transmission and use this information to inform national policy and improve patient safety. From January 1, 2008 to December 31, 2017, the DTAC received 2185 reports; 335 (15%) were classified as a proven/probable donor transmission event. Infections were transmitted most commonly (67%), followed by malignancies (29%), and other disease processes (6%). Forty-six percent of recipients receiving organs from a donor that transmitted disease to at least 1 recipient developed a donor-derived disease (DDD). Sixty-seven percent of recipients developed symptoms of DDD within 30 days of transplantation, and all bacterial infections were recognized within 45 days. Graft loss or death occurred in about one third of recipients with DDD, with higher rates associated with malignancy transmission and parasitic and fungal diseases. Unexpected DDD was rare, occurring in 0.18% of all transplant recipients. These findings will help focus future efforts to recognize and prevent DDD.

The Story of Post-exposure Rabies Prophylaxis at the Pediatric Emergency Department

Objectives This study aimed to determine the epidemiological and medical features of suspected rabies exposures at a pediatric emergency department in a small city center in middle-northern Turkey.

Methods Data were abstracted from a standard “Rabies Suspected Animal Contact Cases Examination Form.” The following information was recorded: sociodemographic and clinical features of the victim, history of rabies vaccination, date of event, time to hospital administration, animal species and its vaccination history with owner records, type of suspected contact, wound care, tetanus prophylaxis, rabies vaccination, and forensic notifications. Immunoprophylaxis was determined as “appropriate” or “inappropriate” in accordance with the Rabies Field Guideline (2014).

Discussion A total of 306 cases were evaluated at the emergency department of the hospital. The age of the victims ranged between 1.5 and 17 years old, and 61.4% of them were males. Cat scratches were the most common source of suspected rabies exposure. Meanwhile, primary wound care and tetanus immunoprophylaxis were the frequent inappropriate medical applications. Rabies prophylaxis was completed in 76.5% of the cases. However, forensic notifications were missing. In addition, the rate of animal immunization was lower than it should be.

Conclusion Our city is rabies free; however, risky exposures are frequent among children. Lack of knowledge about first aid and animal vaccination is revealed to be a major public health problem. Health care workers should follow current guidelines to provide a holistic approach to the treatment of potential rabies exposures.

Review of rabies in Nepal

Rabies is a global problem, but the burden is higher in less developed or developing countries of Asia and Africa. In Nepal, rabies is reported to kill around 500 animals and up to 32 human beings in recent years, with possible under-reporting of cases and deaths. As a prophylactic measure, around 30,000 livestock and 300,000 humans get vaccinated each year in Nepal. This review summarizes the past, present and future perspectives of rabies control and prevention in Nepal. The global strategic plan of World Health Organization (WHO) aims to bring human deaths from dog-transmitted rabies to zero by 2030. To achieve this goal of ‘Zero by 30’, the concerned governmental and non-governmental agencies in Nepal should work together using the One Health concept.

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Rabies is caused by Lyssa virus that is responsible for deaths of 55,000 people annually across the world.

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Dogs are responsible for 95% of rabies cases around the globe and 99% in endemic regions.

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Asia has the highest burden of rabies and India alone accounts for around 35% of world rabies cases.

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In Nepal, less than 35 people have died each year due to rabies.

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One health approach is mandatory to end dog mediated rabies by the year 2030.

Primary amebic meningoencephalomyelitis caused by Naegleria fowleri in a south-central black rhinoceros (Diceros bicornis minor)

CASE DESCRIPTION A 20-year-old female south-central black rhinoceros (Diceros bicornis minor) was evaluated because of an acute onset of CNS deficits. CLINICAL FINDINGS The rhinoceros had no history of illness. Clinical signs included acute lethargy, ataxia, and decreased appetite. Hematologic abnormalities included leukocytosis with neutrophilia and a profound left shift. Results of serum biochemical analysis revealed hypophosphatemia but no other abnormalities. Results of a quantitative PCR assay for West Nile virus and an assay for anti-Neosporum caninum antibodies in serum were negative; the patient was seropositive for multiple Leptospira serovars. TREATMENT AND OUTCOME Antimicrobials and anti-inflammatory agents were administered, but the condition of the rhinoceros worsened overnight; despite treatment with additional anti-inflammatory and antimicrobial agents, IV fluids, and thiamine, it became obtunded and died of respiratory arrest ≤ 24 hours later. Necropsy revealed severe, diffuse, suppurative, and histiocytic meningo-encephalomyelitis involving the cerebrum, cerebellum, and spinal cord. Amebic trophozoites were observed on histologic examination of affected tissue. Infection with Naegleria fowleri was confirmed by results of immuno-histochemical analysis and a multiplex real-time PCR assay. CLINICAL RELEVANCE Findings suggested that south-central black rhinoceros are susceptible to the free-living ameba N fowleri. Ameba-induced meningoencephalomyelitis should be considered as a differential diagnosis for rhinoceros that have an acute onset of neurologic signs. Diagnosis of N fowleri infection in an animal has a profound public health impact because of potential human exposure from the environment and the high fatality rate in people with N fowleri infection.

Emerging and neglected zoonoses in transplant population

Zoonoses represent a problem of rising importance in the transplant population. A close relationship and changes between human, animal and environmental health (“One Health” concept) significantly influence the transmission and distribution of zoonotic diseases. The aim of this manuscript is to perform a narrative review of the published literature on emerging and neglected zoonoses in the transplant population. Many reports on donor-derived or naturally acquired (re-)emerging arboviral infections such as dengue, chikungunya, West Nile, tick-borne encephalitis and Zika virus infection have demonstrated atypical or more complicated clinical course in immunocompromised hosts. Hepatitis E virus has emerged as a serious problem after solid organ transplantation (SOT), leading to diverse extrahepatic manifestations and chronic hepatitis with unfavorable outcomes. Some neglected pathogens such as lymphocytic choriomeningitis virus can cause severe infection with multi-organ failure and high mortality. In addition, ehrlichiosis may be more severe with higher case-fatality rates in SOT recipients. Some unusual or severe presentations of borreliosis, anaplasmosis and rickettsioses were also reported among transplant patients. Moreover, toxoplasmosis as infectious complication is a well-recognized zoonosis in this population. Although rabies transmission through SOT transplantation has rarely been reported, it has become a notable problem in some countries. Since the spreading trends of zoonoses are likely to continue, the awareness, recognition and treatment of zoonotic infections among transplant professionals should be imperative.

Neurologic Complications of Transplantation

Neurologic disturbances including encephalopathy, seizures, and focal deficits complicate the course 10-30% of patients undergoing organ or stem cell transplantation. While much or this morbidity is multifactorial and often associated with extra-cerebral dysfunction (e.g., graft dysfunction, metabolic derangements), immunosuppressive drugs also contribute significantly. This can either be through direct toxicity (e.g., posterior reversible encephalopathy syndrome from calcineurin inhibitors such as tacrolimus in the acute postoperative period) or by facilitating opportunistic infections in the months after transplantation. Other neurologic syndromes such as akinetic mutism and osmotic demyelination may also occur. While much of this neurologic dysfunction may be reversible if related to metabolic factors or drug toxicity (and the etiology is recognized and reversed), cases of multifocal cerebral infarction, hemorrhage, or infection may have poor outcomes. As transplant patients survive longer, delayed infections (such as progressive multifocal leukoencephalopathy) and post-transplant malignancies are increasingly reported.

A mathematical model to describe survival among liver recipients from deceased donors with risk of transmitting infectious encephalitis pathogens

BACKGROUND

Between 2002 and 2013, the organs of 13 deceased donors with infectious encephalitis were transplanted, causing infections in 23 recipients. As a consequence, organs from donors showing symptoms of encephalitis (increased probability of infectious encephalitis (IPIE) organs) might be declined. We had previously characterized the risk of IPIE organs using data available to most transplant teams and not requiring special diagnostic tests. If the probability of infection is low, the benefits of a transplant from a donor with suspected infectious encephalitis might outweigh the risk and could be lifesaving for some transplant candidates.

METHODS

Using organ transplant data and Cox Proportional Hazards models, we determined liver donor and recipient characteristics predictive of post-transplant or waitlist survival and generated 5-year survival probability curves. We also calculated expected waiting times for an organ offer based on transplant candidate characteristics. Using a limited set of actual cases of infectious encephalitis transmission via transplant, we estimated post-transplant survival curves given an organ from an IPIE donor.

RESULTS

54% (1256) of patients registered from 2002-2006 who died or were removed from the waiting list because of deteriorated condition within 1 year could have had an at least marginal estimated benefit by accepting an IPIE liver with some probability of infection, with the odds increasing to 86% of patients if the probability of infection was low (5% or less). Additionally, 54% (1252) were removed from the waiting list prior to their estimated waiting time for a non-IPIE liver and could have benefited from an IPIE liver.

CONCLUSION

Improved allocation and utilization of IPIE livers could be achieved by evaluating the patient-specific trade-offs between (a) accepting an IPIE liver and (b) remaining on the waitlist and accepting a non-IPIE liver after the estimated waiting time.

Dengue virus transmission from live donor liver graft

Arboviral transmission through transplanted organs is rare. We report a highly probable case of dengue viral transmission during live donor liver transplantation. Fever with severe thrombocytopenia was observed in the donor and recipient within 6 and 9 days after transplantation, respectively. Dengue diagnosis was confirmed by testing blood and explant tissue from the donor and recipient using dengue-specific NAT (nucleic acid testing) and serology. Serology indicated the donor had secondary dengue infection that ran a mild course. However, the dengue illness in the recipient was severe and deteriorated rapidly, eventually proving fatal. The recipient's explant liver tissue tested negative for viral RNA indicative of a pretransplant naïve status. The prM-Envelope gene sequence analysis of the donor and recipient viral RNA identified a similar serotype (DENV1) with almost 100% sequence identity in the envelope region. Molecular phylogenetic analysis of donor and recipient viral envelope sequences with regional and local dengue strains further confirmed their molecular similarity, suggesting a probable donor-to-recipient transmission via organ transplantation. Screening of living donors for dengue virus may be considered in endemic regions.

New Approaches to Cryopreservation of Cells, Tissues, and Organs

In this concept article, we outline a variety of new approaches that have been conceived to address some of the remaining challenges for developing improved methods of biopreservation. This recognizes a true renaissance and variety of complimentary, high-potential approaches leveraging inspiration by nature, nanotechnology, the thermodynamics of pressure, and several other key fields. Development of an organ and tissue supply chain that can meet the healthcare demands of the 21st century means overcoming twin challenges of (1) having enough of these lifesaving resources and (2) having the means to store and transport them for a variety of applications. Each has distinct but overlapping logistical limitations affecting transplantation, regenerative medicine, and drug discovery, with challenges shared among major areas of biomedicine including tissue engineering, trauma care, transfusion medicine, and biomedical research. There are several approaches to biopreservation, the optimum choice of which is dictated by the nature and complexity of the tissue and the required length of storage. Short-term hypothermic storage at temperatures a few degrees above the freezing point has provided the basis for nearly all methods of preserving tissues and solid organs that, to date, have proved refractory to cryopreservation techniques successfully developed for single-cell systems. In essence, these short-term techniques have been based on designing solutions for cellular protection against the effects of warm and cold ischemia and basically rely upon the protective effects of reduced temperatures brought about by Arrhenius kinetics of chemical reactions. However, further optimization of such preservation strategies is now seen to be restricted. Long-term preservation calls for much lower temperatures and requires the tissue to withstand the rigors of heat and mass transfer during protocols designed to optimize cooling and warming in the presence of cryoprotective agents. It is now accepted that with current methods of cryopreservation, uncontrolled ice formation in structured tissues and organs at subzero temperatures is the single most critical factor that severely restricts the extent to which tissues can survive procedures involving freezing and thawing. In recent years, this major problem has been effectively circumvented in some tissues by using ice-free cryopreservation techniques based upon vitrification. Nevertheless, despite these promising advances there remain several recognized hurdles to be overcome before deep-subzero cryopreservation, either by classic freezing and thawing or by vitrification, can provide the much-needed means for biobanking complex tissues and organs for extended periods of weeks, months, or even years. In many cases, the approaches outlined here, including new underexplored paradigms of high-subzero preservation, are novel and inspired by mechanisms of freeze tolerance, or freeze avoidance, in nature. Others apply new bioengineering techniques such as nanotechnology, isochoric pressure preservation, and non-Newtonian fluids to circumvent currently intractable problems in cryopreservation.

Rabies Acquired through Mucosal Exposure, China, 2013

In China in 2013, a man acquired rabies after sucking wounds of his son, who had been bitten by a stray dog. The man declined postexposure prophylaxis (hyperimmunoglobulin and vaccine) and died; the son accepted prophylaxis and survived. Physicians should be aware of rabies transmission through mucosal exposure and encourage postexposure prophylaxis.

Donor-derived infections: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation will review the current state of the art of donor-derived infections. Specifically, the guideline will summarize standardized definitions and approaches to defining imputability, updated data on the epidemiology of donor-derived infections, and approaches to risk mitigation against transmission of infections. This update will additionally provide guidance on the use of HIV+ donors in HIV+ recipients, the use of HCV-viremic donors in non-viremic recipients, donors with endemic infections, and donors with bacteremia, meningitis, and encephalitis. Lastly, the guidance will summarize an approach to recipients with a suspected donor-derived infection.

Francisella tularensis Transmission by Solid Organ Transplantation, 20171

In July 2017, fever and sepsis developed in 3 recipients of solid organs (1 heart and 2 kidneys) from a common donor in the United States; 1 of the kidney recipients died. Tularemia was suspected only after blood cultures from the surviving kidney recipient grew Francisella species. The organ donor, a middle-aged man from the southwestern United States, had been hospitalized for acute alcohol withdrawal syndrome, pneumonia, and multiorgan failure. F. tularensis subsp. tularensis (clade A2) was cultured from archived spleen tissue from the donor and blood from both kidney recipients. Whole-genome multilocus sequence typing indicated that the isolated strains were indistinguishable. The heart recipient remained seronegative with negative blood cultures but had been receiving antimicrobial drugs for a medical device infection before transplant. Two lagomorph carcasses collected near the donor's residence were positive by PCR for F. tularensis subsp. tularensis (clade A2). This investigation documents F. tularensis transmission by solid organ transplantation.

Infection in Kidney Transplant Recipients

In organ transplant recipients, impaired inflammatory responses suppress the clinical and radiologic findings of infection. The possible etiologies of infection are diverse, ranging from common bacterial and viral pathogens that affect the entire community to opportunistic pathogens that cause invasive disease only in immunocompromised hosts. Antimicrobial therapies required to treat established infection are often complex, with accompanying risks for drug toxicities and drug interactions with the immunosuppressive agents used to maintain graft function. Rapid and specific diagnosis is essential for successful therapy. The risk of serious infections in the organ transplant patient is largely determined by the interaction between two factors: the patient’s epidemiologic exposures and the patient’s net state of immunosuppression. The epidemiology of infection includes environmental exposures and nosocomial infections, organisms derived from donor tissues, and latent infections from the recipient activated with immunosuppression. The net state of immune suppression is a conceptual framework that measures those factors contributing to risk for infection: the dose, duration, and temporal sequence of immunosuppressive drugs; the presence of foreign bodies or injuries to mucocutaneous barriers; neutropenia; metabolic abnormalities including diabetes; devitalized tissues, hematomas, or effusions postsurgery; and infection with immunomodulating viruses. Multiple factors are present in each host. A timeline exists to aid in the development of a differential diagnosis for infection. The timeline for each patient is altered by changes in prophylaxis and immunosuppressive drugs. For common infections, new microbiologic assays, often nucleic acid based, are useful in the diagnosis and management of opportunistic infections.

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.

Rare and Emerging Viral Infections in the Transplant Population

Viral infections account for a large proportion of emerging infectious diseases, and the agents included in this group consist of recently identified viruses as well as previously identified viruses with an apparent increase in disease incidence. In transplant recipients, this group can include viruses with no recognized pathogenicity in immunocompetent patients and those that result in atypical or more severe disease presentations in the immunocompromised host. In this chapter, we begin by discussing viral diagnostics and techniques used for viral discovery, specifically as they apply to emerging and rare infections in this patient population. Focus then shifts to specific emerging and re-emerging viruses in the transplant population, including human T-cell leukemia virus 1, rabies, lymphocytic choriomeningitis virus, human bocavirus, parvovirus 4, measles, mumps, orf, and dengue. We have also included a brief discussion on emerging viruses and virus families with few or no reported cases in transplant recipients: monkeypox, nipah and hendra, chikungunya and other alphaviruses, hantavirus and the Bunyaviridae, and filoviruses. Finally, concerns regarding infectious disease complications in xenotransplantation and the reporting of rare viral infections are addressed. With the marked increase in the number of solid organ and hematopoietic stem cell transplants performed worldwide, we expect a corresponding rise in the reports of emerging viral infections in transplant hosts, both from known viruses and those yet to be identified.

Is This Organ Donor Safe?: Donor-Derived Infections in Solid Organ Transplantation

Infection is an inevitable complication of solid organ transplantation. Unrecognized infection may be transmitted from a donor and result in disseminated disease in the immunosuppressed host. Recent outbreaks of deceased donor-derived infections resulting in high rates of mortality and severe morbidity have emphasized the need to be cautious in using donors with possible meningoencephalitis. Screening of organ donors for potential transmissible infections is paramount to improving transplantation outcomes.

Is This Organ Donor Safe?: Donor-Derived Infections in Solid Organ Transplantation

Infection is an inevitable complication of solid organ transplantation. Unrecognized infection may be transmitted from a donor and result in disseminated disease in the immunosuppressed host. Recent outbreaks of deceased donor-derived infections resulting in high rates of mortality and severe morbidity have emphasized the need to be cautious in using donors with possible meningoencephalitis. Screening of organ donors for potential transmissible infections is paramount to improving transplantation outcomes.

The shift in rabies epidemiology in France: time to adjust rabies post-exposure risk assessment

The epidemiology of rabies in France and western Europe has changed during the past 22 years. In France, rabies in non-flying terrestrial mammals was declared to be eliminated in 2001, and the risk of rabies is now limited to contact with bats, rabid animals illegally imported from rabies-enzootic countries and traveller exposure in enzootic areas. We analysed the epidemiology of rabies in France from 1995 to 2016, describing and analysing data on human rabies surveillance as well as data on post-exposure prophylaxis (PEP) collected from the network of French antirabies clinics. Over the study period, seven individuals were diagnosed with rabies in France, all of whom were infected outside mainland France. PEP data analysis revealed an expected overall decrease in PEP administration for individuals exposed in mainland France, but there was still overuse of anti-rabies drugs, given the very low epidemiological risk. On the other hand, a significant increase in PEP delivered to individuals exposed abroad was evidenced. These epidemiological trends indicate that clear guidelines should be provided to support physicians' efforts to adjust rabies risk assessment to the evolution of the epidemiological situation.

The first report evaluating the post-exposure rabies prophylaxis in children exposed to animals in the Lublin Province (Eastern Poland) in 2010-2016 - a retrospective study

INTRODUCTION

Rabies continues to be one of the most important viral diseases and remains a significant threat to public health across the globe. The World Health Organization (WHO) has determined that most rabies cases occur in children. Dog bites on humans are a major public-health problem. Poland has not achieved rabies free status yet. Post-exposure prophylaxis (PEP) in humans can effectively prevent death after exposure to a potentially infected animal.

THE AIM

The main objective of this study was to estimate the frequency of PEP among children exposed to animals, who had attended consultations at the Department of Infectious Diseases for Children in the Jan Boży Hospital in Lublin.

PATIENTS AND METHODS

We retrospectively analyzed the medical records from the period of 2010-2016 of all pediatric patients (0-17 years of age) who had been exposed to animals and attended consultations at the Department of Infectious Diseases for Children in the Jan Boży Hospital in Lublin.

RESULTS

During the studied period, 519 children who had been exposed to animals attended consultations, and a prophylactic procedure consisting of active immunization was applied to 32.8%. The male children accounted for 55.3%. The mean age was 9.2 years. The biggest group of children (406) had been exposed to dogs, 62 children to cats, and 15 to rats. Most children had upper-limbs injuries. During the studied period, i.e. 2010-2016, there were 1713 confirmed cases of rabid animals in Poland, and 60 cases were recorded in the Lublin Province. We did not observe any cases of rabies in our exposed and vaccinated patients.

CONCLUSIONS

The number of rabid animals in the Lublin Province had decreased to low levels, but the expected decrease in the number of PEP's administered did not occur. Since all children were vaccinated in accordance with the recommendations, the possible reason for vaccination's being administered in the quantities greater than the number of rabid animals recorded in the Lublin Province are bites by animals unavailable for veterinary observations and also the lack of more frequent reports regarding the current epizootic situation of rabies. The use of rabies immunoglobulin (RIG) in children in the Lublin Province is at a very low level, i.e. at 0.58%. The yearly numbers of exposed pediatric patients were at similar levels, which indicates that education programs should be introduce to reduce the number of animal bites in children.

Assessment of risk for transplant-transmissible infectious encephalitis among deceased organ donors

BACKGROUND

There were 13 documented clusters of infectious encephalitis transmission via organ transplant from deceased donors to recipients during 2002-2013. Hence, organs from donors diagnosed with encephalitis are often declined because of concerns about the possibility of infection, given that there is no quick and simple test to detect causes of infectious encephalitis.

METHODS

We constructed a database containing cases of infectious and non-infectious encephalitis. Using statistical imputation, cross-validation, and regression techniques, we determined deceased organ donor characteristics, including demographics, signs, symptoms, physical exam, and laboratory findings, predictive of infectious vs non-infectious encephalitis, and developed a calculator which assesses the risk of infection.

RESULTS

Using up to 12 predictive patient characteristics (with a minimum of 3, depending on what information is available), the calculator provides the probability that a donor may have infectious vs non-infectious encephalitis, improving the prediction accuracy over current practices. These characteristics include gender, fever, immunocompromised state (other than HIV), cerebrospinal fluid elevation, altered mental status, psychiatric features, cranial nerve abnormality, meningeal signs, focal motor weakness, Babinski's sign, movement disorder, and sensory abnormalities.

CONCLUSION

In the absence of definitive diagnostic testing in a potential organ donor, infectious encephalitis can be predicted with a risk score. The risk calculator presented in this paper represents a prototype, establishing a framework that can be expanded to other infectious diseases transmissible through solid organ transplantation.

Transmission of rabies through solid organ transplantation: a notable problem in China

BACKGROUND

Due to the increasing number of DCD transplantations since 2015, the transmission of rabies through solid organ transplantation has become a notable problem in China and has attracted the attention of the public.

CASE PRESENTATION

From 2015 to 2017, four solid organ recipients in our centre were successively diagnosed with rabies that was considered to have been transmitted from two donors who died due to viral encephalitis of unknown cause and acute disseminated encephalomyelitis. The incubation periods were 44, 48, 158 and 303 days. The four patients had neurological symptoms associated with rabies and died. The survival times were 44, 34, 8 and 6 days. Another kidney transplant recipient received timely post-exposure prophylaxis and has remained asymptomatic.

CONCLUSIONS

Organs should be discarded whenever rabies is confirmed or suspected, especially in cases diagnosed as encephalitis of unknown cause. It is important to establish a supervisory system to manage donor-derived infectious diseases. When rabies-infected donor organs are inadvertently transplanted, the recipients must receive post-exposure prophylaxis in a timely manner, which may be the only possible effective method to prevent the transmission of rabies.

Rabies Virus Transmission in Solid Organ Transplantation, China, 2015-2016

We report rabies virus transmission among solid organ transplantation recipients in Changsha, China, in 2016. Two recipients were confirmed to have rabies and died. Our findings suggest that more attention should be paid to the possibility of rabies virus transmission through organ transplantation for clinical and public health reasons.

Epidemiological and Genetic Characteristics of Rabies Virus Transmitted Through Organ Transplantation

In January 2016, two patients died of rabies after receiving kidney transplants from a common organ donor at a hospital in Changsha, Hunan, China. The medical records, epidemiological data of the organ donor, two kidney and a liver recipients were reviewed. Intravitam saliva samples of the two kidney recipients were tested for rabies virus (RABV) using real-time RT-PCR, and the nucleoprotein (N) gene was amplified and sequenced by Sanger sequencing. Whole genome sequences were analyzed using next-generation sequencing. The N genes of the two kidney recipients showed 100% nucleic acid identity. Phylogenetic analysis of the complete genome, N and glycoprotein (G) genes indicated that the RABV was homologous with dog isolates from the Hunan province and belong to the China I lineage, which is widespread in China. The organ donor was a 22-month-old boy who died from unknown acute progressive encephalitis. After undergoing sub-hypothermia hibernation therapy, rabies-associated symptoms were atypical, and rabies was neglected because serum RABV-specific antibodies were negative. An unknown wound on the forehead of the donor was found 2 months before the onset of symptoms. Based on the clinical, epidemiological, and molecular findings, we speculated that the RABV initially originated in the donor from a dog bite, and was then transmitted to the recipients by organ transplantation. An uncertain exposure history and misdiagnosis played important roles in the spread of the RABV. Rabies should be considered in patients with acute progressive encephalitis of unexplained etiology, especially in potential organ donors.

The spread and evolution of rabies virus: conquering new frontiers

Rabies is a lethal zoonotic disease that is caused by lyssaviruses, most often rabies virus. Despite control efforts, sporadic outbreaks in wildlife populations are largely unpredictable, underscoring our incomplete knowledge of what governs viral transmission and spread in reservoir hosts. Furthermore, the evolutionary history of rabies virus and related lyssaviruses remains largely unclear. Robust surveillance efforts combined with diagnostics and disease modelling are now providing insights into the epidemiology and evolution of rabies virus. The immune status of the host, the nature of exposure and strain differences all clearly influence infection and transmission dynamics. In this Review, we focus on rabies virus infections in the wildlife and synthesize current knowledge in the rapidly advancing fields of rabies virus epidemiology and evolution, and advocate for multidisciplinary approaches to advance our understanding of this disease.

Unexpected donor-derived infectious transmissions by kidney transplantation: A systematic review

BACKGROUND

Unexpected donor-derived transmission of infections is rare, but is associated with significant morbidity and mortality. We aimed to provide an overview of published cases on unexpected infectious transmissions.

METHODS

We systematically reviewed all published evidence describing any unexpected donor-derived viral, bacterial, fungal, and parasitic infections in kidney transplant recipients.

RESULTS

In all, 119 studies (case reports [n = 36], case series [n = 78], cohort studies [n = 2], and case-control studies [n = 3]) involving 139 donors and 207 kidney recipients were included. Donor-derived viral (n = 116, 56.0%) infections were most prevalent, followed by bacterial (32, 15.5%), fungal (32, 15.5%), and parasitic (27, 13.0%) infections. The most commonly reported viral infections were human immunodeficiency virus (HIV) (n = 20, 9.7%), human T-cell lymphotrophic virus (HTLV) (n = 20, 9.7%), and West Nile virus (WNV) (n = 13, 6.3%). The most frequent bacterial infections were caused by Mycobacterium tuberculosis (10, 4.8%) and Pseudomonas aeruginosa (9, 4.3%). Candida species were the most frequent causes of fungal donor-derived infections (8, 3.9%). Toxoplasma gondii accounted for seven (3.4%) cases of transmitted parasitic infections. Patients with rabies experienced the highest probability of recipient death from virus-related complications at 90.0%, within a median time of 2.8 months after transplantation.

CONCLUSION

The frequency of donor-derived infectious transmission appears low in kidney transplantation, with viral transmissions being most commonly reported overall.

Pediatrics and donor-derived disease transmission: The US OPTN experience

PDDTE are tracked by the OPTN Ad Hoc DTAC. Specific evaluation of potential transmissions from pediatric deceased donors or the impact of donor-derived disease transmissions to pediatric organ recipients has not been previously undertaken. PDDTE reported to the DTAC between 2008 and 2013 were reviewed, characterized as proven, probable, possible, IWDT, unlikely, or excluded for both the whole event and each individual recipient. Pediatric donors and recipients were defined as being 0-17 years of age. Analysis was undertaken to characterize potential disease transmission from pediatric donors to adult or pediatric recipients and also to evaluate potential transmission from all donors to pediatric recipients. P/P cases were further analyzed. A total of 5238 pediatric deceased US donors accounted for 17 456 organ transplants during the study period; 103 PDDTE reports arose from these donors (2.0%). PDDTE were characterized as P/P (15%), possible (13%), IWDT (9%), unlikely, and excluded (63%). Disease was transmitted to 22 of 54 potentially exposed (adult and pediatric) recipients with six attributable deaths. An infectious pathogen accounted for 13/15 of the P/P PDDTE associated with pediatric donors, affecting 19 of 50 potentially exposed recipients and resulting in five deaths. Four separate viral pathogens from six donors accounted for P/P transmissions to 11 recipients with the unanticipated transmission of CMV most common. No pediatric donor transmitted HIV, HBV, or HCV. Bacteria, fungi, and parasites accounted for three (all staphylococci), three (Zygomycetes and Histoplasma), and two (both Toxoplasma) P/P transmissions from seven donors, respectively. From the recipient side, 11/11,188 pediatric recipient deceased and living donor transplants during the study period were associated with a P/P PDDTE (<0.1%) with infectious pathogens accounting for 9/11 P/P events. Infections were split among pathogen categories (bacteria 2, viruses 3, parasites 3, and fungi 1). Reporting rates of PDDTE involving pediatric donors were very low and similar to rates from all donors, with resulting P/P transmissions occurring in only 0.1% of exposed recipients, but transmissions were associated with six deaths. Rates of P/P transmission to pediatric recipients from any donor (<0.1%) were also very low and similar to that of all recipients. Additional studies are needed to compare the pattern and outcome of donor-derived disease transmission from and to pediatric and adult donor and recipients.

Donor-derived infections in solid organ transplant patients: toward a holistic approach

PURPOSE OF REVIEW

Solid organ demand far exceeds organ supply. Strategies to increase the donor pool include the liberalization of selection criteria without increasing the risk of unexpected donor-derived infection (DDI), a rare complication of transplantation carrying high morbidity and mortality. We review the challenging aspects in the prevention of DDI, focusing on the complexities of data sharing and efficient communication and the role infectious diseases specialists play in the process.

RECENT FINDINGS

Advances in donor screening, transmission recognition and reporting allow for a better estimation of the risk of DDI. However, there is great variability in the frequency and methods with which organ procurement organizations report transmission events.Moreover, the Scientific Registry of Transplant Recipients provides limited donor and recipient outcome infectious diseases related data. Infectious disease contribution to the allocation process has been found to improve organ donation efficiency and communication between involved parties. Although communication gaps are strongly associated with infection transmission (relative risk 2.36%, confidence interval 1.48-3.78), effective communication minimizes or prevents infection in transplant recipients (X(1) 13.13, P = 0.0003).

SUMMARY

Prospective research is still required to define optimal screening protocols and further prevent transmission of infection. A holistic approach is likely to result in enhanced transplantation safety. Toward this goal, development of standards of investigation; improvement in reporting and data sharing; and strategies ensuring coordinated and rapid communication among parties involved in the allocation process need to be pursued.

Infection in Kidney Transplantation

Infection is an important cause of morbidity and mortality after kidney transplantation. It has been estimated that 70% of kidney transplant recipients will experience an infection episode within the first 3 years after transplantation (Dharnidharka et al. 2007). After cardiovascular disease, infection is the second leading cause of death in recipients with allograft function (Snyder et al. 2009). The immunosuppressive therapy required to prevent organ rejection places the kidney transplant recipient at increased risk for donor-derived, nosocomial, and community-acquired infections as well as reactivation of latent pathogens. Pretransplant screening, immunizations, and optimal antibacterial and antiviral prophylaxis can help to reduce the impact of infection. Awareness of the approach to infection in the transplant recipient including diagnostic and management strategies is essential to optimizing outcomes.

Case Report: Failure of Therapeutic Coma in Rabies Encephalitis

Rabies encephalitis is a fulminant, almost universally fatal infection involving the central nervous system. A unique treatment protocol, including anti-exicitotoxic therapy and induced coma was credited with the survival of a vaccinated teenager with bat rabies encephalitis in 2005. However, multiple efforts to replicate this expensive and intense protocol have not been successful. In this article, we report the failure of the protocol in Indian patients with canine-acquired rabies and elucidate the potential explanations for the failure of the protocol in our patients.