A 70-year-old woman has died, and a 57-year-old man is critically ill in a Boston hospital after each received a kidney from a donor infected with a hard-to-detect virus, health authorities said yesterday.
The donor, a 49-year-old homeless man who suffered irreversible brain damage after cardiac arrest, carried a germ called lymphocytic choriomeningitis virus, or LCMV, the same infection that killed three transplant patients from Massachusetts and Rhode Island in 2005. The virus, most often transmitted by rodents, is usually unnoticed by healthy people who suffer no more than flulike symptoms.
Knowing that organs perish quickly, doctors test donors for what is easily analyzed, such as the AIDS virus, hepatitis, and a common herpes germ. But the lack of quick tests for less common conditions prevents screening for diseases such as the lymphocytic choriomeningitis virus.
Because the demand for organs always far exceeds the supply, recipients will accept organs even from high-risk donors such as the homeless. Waiting too long for a new kidney, liver, or heart can prove riskier.
"People are literally dying for organs," said Dr. Alfred DeMaria, top disease tracker at the Massachusetts Department of Public Health. "The list of potential things you can test for is enormous. But balancing that against the risk of not getting the organs, you have to make some decisions about what's feasible and what's not feasible to test for."
The homeless donor died in mid-March. After his family authorized the removal of viable organs, doctors took his kidneys. He had been tested for the AIDS virus, the liver diseases hepatitis B and C, and other diseases regularly checked by the New England Organ Bank, the region's organ procurement agency. There was no evidence of worrisome infections.
Still, his status as a man who had lived on the street, potentially exposed to a host of dangerous germs, led transplant surgeons to brand him as a high-risk donor.
Transplant surgeons at the hospitals with the two potential recipients - the woman was at Boston Medical Center, the man at Beth Israel Deaconess Medical Center - alerted the patients that the donor was regarded as high risk. The surgeons and patients decided to proceed.
"We all know that as much as we explain to the patients and inform them, they're relying on us and our medical judgment about whether this is a safe transplant," said Dr. Douglas W. Hanto, chief of the Division of Transplantation at Beth Israel Deaconess. "We feel a tremendous sense of responsibility to the patient and their family and feel terrible that this patient has had this infection and a bad outcome.
"But, on the other hand, we see patients who die every day on dialysis" awaiting a kidney transplant, he said.The 57-year-old man transplanted at Hanto's hospital had lingered four years on the waiting list for a kidney. According to the United Network for Organ Sharing, an independent agency that sets organ procurement policies, 80,130 patients in the United States currently need a kidney.
It was the woman transplanted at Boston Medical who got sicker sooner after returning home. Like the donor and the other recipient, the woman was not identified by health authorities, who cited patient confidentiality laws.
The woman returned to Boston Medical about two weeks after her surgery, said Dr. Greg Grillone, the hospital's interim chief medical officer. She had a fever, diarrhea, "but oddly, symptoms not specific to the kidney," Grillone said.
Her condition kept deteriorating and, in mid-April, the woman died. Doctors at the hospital were stumped. There was no obvious cause of her precipitous demise.
But it turned out that one of the surgeons involved in the case, Dr. Amitabh Gautam, had been connected to the 2005 Rhode Island and Massachusetts transplant cases.
He became suspicious that the Boston Medical patient had the same virus and alerted the federal Centers for Disease Control and Prevention. The virus has been known to have spread via transplant only two other times, in Wisconsin and Australia.
"Interestingly, what happened was this doctor had seen this before and thought, 'OK, this is a long shot, but I have seen it before and it can happen,' " Grillone said.
"If you take your car to the auto dealer with some very, very rare problem and you're lucky enough to get the mechanic who saw that same problem three years ago in the same make or model of the car, he might think: 'Oh, I saw this same problem three years ago. it might be the same problem," he said.
The man who had received his kidney at Beth Israel Deaconess returned with a fever 2 1/2 weeks after the surgery. On April 18, the doctors there got word that the Boston Medical patient had died. A transplant specialist at Beth Israel Deaconess also speculated that the virus might be at fault.
Samples from the deceased donor and the two patients were rushed to the CDC in Atlanta. All three tested positive for the virus, and investigators said all evidence points to the donor. The 57-year-old recipient remains in intensive care and is receiving the only drug known to possibly treat the virus.
"I don't believe this ever put the general public at risk," said Dr. Anita Barry, who leads the Boston Public Health Commission's investigation of the infections. "You have to be very, very unlucky to get LCMV from a transplant."
The virus is not transmitted casually from person-to-person; in addition to transplants, the only identified human transmissions have been from mother to fetus. Most people who are exposed catch it from the droppings of rodents, including wild animals and pets.
Because the virus causes few health problems in those who contract it, there has been little incentive to develop a rapid test.
The only tests currently available take time and are not widely available, said Dr. Eileen Farnon, a CDC medical epidemiologist.
"If you had a few days or a week for testing you could do that," Farnon said. "But in general that's not how the organ transplantation business works."
Stephen Smith can be reached at stsmith@globe.com.Original here
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