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Original Investigation
July 24/31, 2013

Raccoon Rabies Virus Variant Transmission Through Solid Organ Transplantation

Author Affiliations
  • 1Poxvirus and Rabies Branch, Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
  • 2Epidemic Intelligence Service, Scientific Education and Professional Development Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia
  • 3Office of Blood, Organ, and Other Tissue Safety, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
  • 4Maryland Department of Health and Mental Hygiene, Baltimore
  • 5Infectious Diseases Pathology Branch, Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
  • 6Veterans Affairs Medical Center, Washington, DC
  • 7George Washington University School of Medicine, Washington, DC
  • 8North Carolina Division of Public Health, Raleigh
  • 9University of Miami Miller School of Medicine–Miami Transplant Institute, Miami, Florida
  • 10Northwestern University Feinberg School of Medicine, Chicago, Illinois
  • 11Walter Reed National Military Medical Center, Bethesda, Maryland
  • 12Emory University School of Medicine, Atlanta, Georgia
JAMA. 2013;310(4):398-407. doi:10.1001/jama.2013.7986
Abstract

Importance  The rabies virus causes a fatal encephalitis and can be transmitted through tissue or organ transplantation. In February 2013, a kidney recipient with no reported exposures to potentially rabid animals died from rabies 18 months after transplantation.

Objectives  To investigate whether organ transplantation was the source of rabies virus exposure in the kidney recipient, and to evaluate for and prevent rabies in other transplant recipients from the same donor.

Design  Organ donor and all transplant recipient medical records were reviewed. Laboratory tests to detect rabies virus–specific binding antibodies, rabies virus neutralizing antibodies, and rabies virus antigens were conducted on available specimens, including serum, cerebrospinal fluid, and tissues from the donor and the recipients. Viral ribonucleic acid was extracted from tissues and amplified for nucleoprotein gene sequencing for phylogenetic comparisons.

Main Outcomes and Measures  Determination of whether the donor died from undiagnosed rabies and whether other organ recipients developed rabies.

Results  In retrospect, the donor’s clinical presentation (which began with vomiting and upper extremity paresthesias and progressed to fever, seizures, dysphagia, autonomic dysfunction, and brain death) was consistent with rabies. Rabies virus antigen was detected in archived autopsy brain tissue collected from the donor. The rabies viruses infecting the donor and the deceased kidney recipient were consistent with the raccoon rabies virus variant and were more than 99.9% identical across the entire N gene (1349/1350 nucleotides), thus confirming organ transplantation as the route of transmission. The 3 other organ recipients remained asymptomatic, with rabies virus neutralizing antibodies detected in their serum after completion of postexposure prophylaxis (range, 0.3-40.8 IU/mL).

Conclusions and Relevance  Unlike the 2 previous clusters of rabies virus transmission through solid organ transplantation, there was a long incubation period in the recipient who developed rabies, and survival of 3 other recipients without pretransplant rabies vaccination. Rabies should be considered in patients with acute progressive encephalitis of unexplained etiology, especially for potential organ donors. A standard evaluation of potential donors who meet screening criteria for infectious encephalitis should be considered, and risks and benefits for recipients of organs from these donors should be evaluated.

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