A 20-year-old Air Force recruit who died of rabies had symptoms of the disease but wasn’t tested before his organs were transplanted to four patients, one of whom died of rabies nearly 18 months later, federal health officials said Friday.
The three other organ recipients are getting rabies shots and haven’t displayed any symptoms. Doctors at the Centers for Disease Control and Prevention (CDC) declined to speculate on their chances for survival.
“This case is so unique and atypical that we cannot make predictions,” said Richard Franka, acting leader of the CDC’s rabies team.
Dr. Matthew Kuehnert, director of the agency’s Office of Blood, Organ, and Other Tissue Safety, said investigators don’t know why doctors in Florida didn’t test the donor for rabies before offering his kidneys, heart and liver to people in Florida, Georgia, Illinois and Maryland.
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The man in Maryland who received the transplant died in late February; it was the state’s first fatal case of rabies in 36 years. The Defense Department said he was an Army veteran who had transplant surgery at Walter Reed National Military Medical Center.
The donor had seizures and encephalitis — a brain inflammation that can be caused by rabies — but those symptoms can also be caused by a variety of bacterial, viral and other more common conditions. “Rabies is very unusual and it can look like a lot of different things,” Kuehnert said. “I personally can’t say I would have been able to make the correct diagnosis had I been there.”
Infections of any type spread by transplanted organs are uncommon. Fewer than 1 percent of dead donors are found to have infected recipients, says the Organ Procurement and Transplantation Network, which oversees transplants nationwide.
When infections occur, they can be deadly, because drugs used to prevent patients from rejecting transplants work by suppressing the immune system, leaving them vulnerable to infection.
Transplant specialists walk a fine line. Organs are scarce and doctors are loath to discard anything that could save a life. Time is of the essence: Once a donor dies, the organs start to deteriorate and must be used quickly.
Extensive testing is done for HIV, hepatitis and other diseases but cannot be done for every possible infection.
Rabies is rare, and donors are not tested for it unless there is reason to suspect it.
In June 2012, the United Network for Organ Sharing (UNOS) warned transplant teams that “extreme caution is urged” before using organs from people with encephalitis that might be caused by untreatable viruses such as rabies and West Nile. It did not issue a blanket prohibition.
“The devil is in the details,” said Dr. Michael Green, an infectious-diseases physician at the University of Pittsburgh who heads UNOS’s Disease Transmission Advisory Committee. “But clearly one needs to be exceptionally cautious.”
The donor, who had fallen into a coma, died in September 2011 at a Florida medical facility. His cause of death was listed as encephalitis of unknown origin, Florida Department of Health epidemiologist Dr. Carina Blackmore said.
He was a North Carolina resident who was training to become an aviation mechanic in Pensacola, Fla., when he got sick, Defense Department spokeswoman Cynthia Smith said. When the donor first became ill, physicians thought he had food poisoning from eating fish from the Gulf of Mexico.
Public- and military-health officials said they’re trying to identify people in all five states who had close contact with the donor or the recipients, whose identities haven’t been publicly disclosed.
Those people might also need treatment, which consists of an injection of rabies-fighting antibodies and four vaccination shots over a month.
The CDC hasn’t determined how the donor got the raccoon rabies virus that killed him and the Maryland man.
The CDC said there has been just one other reported instance of rabies transmission by transplanted solid organs, a 2004 case in which all four recipients died after receiving tissue from an infected donor. There have been at least eight instances of rabies transmission through transplanted corneas, CDC spokeswoman Barbara Reynolds said.
The Maryland death was announced Tuesday by state health officials. State Public Health Veterinarian Katherine Feldman said doctors suspected before he died that he had rabies, and they knew about his kidney transplant, but considered a rabies-infected kidney to be a remote possibility.
Material from The New York Times and The Washington Post is included in this report.