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Update: Investigation of Rabies Infections in Organ Donor and
Transplant Recipients --- Alabama, Arkansas, Oklahoma, and Texas, 2004
On July 1, 2004, CDC reported laboratory confirmation of rabies as the cause of encephalitis in an organ donor and
three organ recipients at Baylor University Medical Center (BUMC) in Dallas, Texas
(1). Hospital and public health officials
in Alabama, Arkansas, Oklahoma, and Texas initiated public health investigations to identify donor and recipient contacts,
assess exposure risks, and provide rabies postexposure prophylaxis (PEP). As of July 9, PEP had been initiated in approximately
174 (19%) of 916 persons who had been assessed for exposures to the organ recipients or the donor. As a result of its public
health investigation, the Arkansas Department of Health determined that the donor had reported being bitten by a bat
(Frank Wilson, M.D., Arkansas Department of Health, personal communication, 2004).
On July 7, CDC was notified of an additional organ transplant patient at BUMC who had died of encephalopathy
of unknown origin in early June. This case was detected as part of an ongoing review of transplant-patient autopsies. The
patient, who had end-stage liver disease, had received a liver transplant at BUMC in early May 2004. The patient
remained hospitalized with transplant-related complications and began having neurologic abnormalities in early June, progressing
to seizure, coma, and death. On July 7, pathologists at BUMC identified intracytoplasmic inclusions, suggestive of rabies,
in neurons in multiple areas of the brain.
Specimens from the recipient were sent to CDC on July 7, and direct fluorescent antibody and
immunohistochemical staining procedures confirmed the presence of rabies viral
antigens in multiple areas of the brain, including the
hippocampus, midbrain, pons, medulla, and cerebellum. Similar to the findings with the three previously known rabies-infected
transplant recipients, preliminary antigenic characterization of the agent was consistent with a rabies virus variant associated
with insectivorous bats. On July 8, CDC laboratory testing of tissues and serum from the donor who provided the liver yielded
no evidence of infection with rabies virus.
Review of surgical procedures at BUMC determined that a segment of iliac artery recovered from the donor
subsequently determined to have rabies had been stored at the facility for future use in liver transplants. This artery segment
subsequently was used in the transplantation of the liver in the most
recently identified rabies-infected recipient. Investigation of
rabies transmission sources is ongoing, although current evidence suggests that the artery segment originating from the
rabies-infected donor likely is the source of the latest rabies infection. Identification of contacts of this liver recipient is under
way, and initiation of PEP when indicated or as appropriate is in progress.
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