Transmission of Eastern Equine Encephalitis Virus From an Organ Donor to 3 Transplant Recipients

Abstract

Background In fall 2017, 3 solid organ transplant (SOT) recipients from a common donor developed encephalitis within 1 week of transplantation, prompting suspicion of transplant-transmitted infection. Eastern equine encephalitis virus (EEEV) infection was identified during testing of endomyocardial tissue from the heart recipient. Methods We reviewed medical records of the organ donor and transplant recipients and tested serum, whole blood, cerebrospinal fluid, and tissue from the donor and recipients for evidence of EEEV infection by multiple assays. We investigated blood transfusion as a possible source of organ donor infection by testing remaining components and serum specimens from blood donors. We reviewed data from the pretransplant organ donor evaluation and local EEEV surveillance. Results We found laboratory evidence of recent EEEV infection in all organ recipients and the common donor. Serum collected from the organ donor upon hospital admission tested negative, but subsequent samples obtained prior to organ recovery were positive for EEEV RNA. There was no evidence of EEEV infection among donors of the 8 blood products transfused into the organ donor or in products derived from these donations. Veterinary and mosquito surveillance showed recent EEEV activity in counties nearby the organ donor’s county of residence. Neuroinvasive EEEV infection directly contributed to the death of 1 organ recipient and likely contributed to death in another. Conclusions Our investigation demonstrated EEEV transmission through SOT. Mosquito-borne transmission of EEEV to the organ donor was the likely source of infection. Clinicians should be aware of EEEV as a cause of transplant-associated encephalitis.

The Immune Response to Eastern Equine Encephalitis Virus Acquired Through Organ Transplantation

“…In previous reports, EEEV IgM was detected as early as 1 day after the onset of symptoms, peaks 1-3 weeks after the onset of illness, and may remain positive for up to 3 months (Calisher et al, 1986a,b). The patient in this study had onset of encephalitis symptoms on DOI 7 (Pouch et al, 2018), making the observed decline in IgM between DOI 39 and DOI 48 consistent with a peak titer occurring in the first 3 weeks after symptom onset. Unfortunately, residual cerebrospinal fluid (CSF) samples were not available for testing from this EEEV patient to document the longitudinal course of CSF antibody production, although clinical testing revealed a positive CSF IgM antibody test on DOI 9 (Pouch et al, 2018).…”

“…EEEV was diagnosed on day 8 after transplantation based on positive EEEV IgM antibodies in cerebrospinal fluid. She had poor neurological recovery with repeat imaging demonstrating cerebral vasculitis and died 3 months post-transplantation (Pouch et al, 2018).…”

“…Although usually transmitted by mosquitoes, a series of three cases of EEEV infection among organ transplant recipients secondary to transmission from a single infected donor in 2017 was recently described; EEEV-related complications contributed to the death of two of the transplant recipients (Pouch et al, 2018). We describe the humoral and cellular immune response to EEEV in the liver transplant recipient, who was a 40 year old woman with a history of autoimmune hepatitis who received her second liver transplant from the donor retrospectively identified as infected with EEEV.…”

“…We describe the humoral and cellular immune response to EEEV in the liver transplant recipient, who was a 40 year old woman with a history of autoimmune hepatitis who received her second liver transplant from the donor retrospectively identified as infected with EEEV. The organ donor had detectable EEEV RNA in the blood at the time of organ collection but no detectable EEEV antibodies (Pouch et al, 2018). The liver recipient subsequently developed fevers the day following transplant and confusion 6 days following transplant leading to obtundation due to encephalitis with multiple non-enhancing regions of restricted diffusion in the basal ganglia, temporal lobes, and thalami on MRI (Pouch et al, 2018).…”

“…The organ donor had detectable EEEV RNA in the blood at the time of organ collection but no detectable EEEV antibodies (Pouch et al, 2018). The liver recipient subsequently developed fevers the day following transplant and confusion 6 days following transplant leading to obtundation due to encephalitis with multiple non-enhancing regions of restricted diffusion in the basal ganglia, temporal lobes, and thalami on MRI (Pouch et al, 2018). EEEV was diagnosed on day 8 after transplantation based on positive EEEV IgM antibodies in cerebrospinal fluid.…”