Transmission of Balamuthia mandrillaris Through Solid Organ Transplantation: Utility of Organ Recipient Serology to Guide Clinical Management

Abstract

A liver, heart, iliac vessel, and two kidneys were recovered from a 39-year-old man who died of traumatic head injury and were transplanted into five recipients. The liver recipient eighteen days post-transplantation presented with headache, ataxia and fever, followed by rapid neurologic decline and death. Diagnosis of granulomatous amebic encephalitis (GAE) was made on autopsy. Balamuthia mandrillaris infection was confirmed with immunohistochemical and PCR assays. Donor and recipients' sera were tested for B. mandrillaris antibodies. Donor brain was negative for Balamuthia by immunohistochemistry and PCR; donor serum Balamuthia antibody titer was positive (1:64). Antibody titers in all recipients were positive (range, 1:64 to 1:512). Recipients received a 4- to 5-drug combination of miltefosine or pentamidine, azithromycin, albendazole, sulfadiazine, and fluconazole. Nausea, vomiting, elevated liver transaminases and renal insufficiency was common. All other recipients survived and have remained asymptomatic 24-months post-transplant. This is the third donor-derived Balamuthia infection cluster described in solid organ transplant recipients in the U.S. As Balamuthia serologic testing is only available through a national reference laboratory, it is not feasible for donor screening, but may be useful to determine exposure status in recipients and to help guide chemotherapy.

Three Cases of Neurologic Syndrome Caused by Donor-Derived Microsporidiosis

“…Although a laboratory-confirmed donor-derived cluster of microsporidiosis has been reported ( 7 ), the cluster reported here is unique in that all 3 recipients experienced neurologic disease in the absence of gastrointestinal signs and symptoms, an extremely rare presentation of disseminated microsporidiosis. Previously, CDC has described infection with West Nile virus, rabies, lymphocytic choriomeningitis virus, and Balamuthia mandrillaris , transmitted through solid organ transplantation and manifested as encephalitis among recipients ( 19 – 22 ). The cluster reported here adds microsporidiosis to the list and points to the need for clinicians to maintain awareness of this pathogen when evaluating transplant recipients who exhibit signs or symptoms suggestive of encephalitis.…”

Centrofacial Balamuthiasis: case report of a rare cutaneous amebic infection

“…Transmission of free‐living ameba from the environment to hosts usually occurs via skin breakage or via the respiratory system . Alternate modes of infection reported in literature include organ transplantation . B. mandrillaris infection occurs in both immunocompromised and immunocompetent hosts, particularly children …”

“…15 Alternate modes of infection reported in literature include organ transplantation. 16 B. mandrillaris infection occurs in both immunocompromised and immunocompetent hosts, particularly children. 1,2,17 Cutaneous involvement alone is an unusual presentation of balamuthiasis in the United States where most cases do not have skin lesions at all (only GAE), and if skin lesions are present, they exist in combination with CNS manifestations (CDC unpublished data).…”

Infection and Cancer Screening in Potential Living Donors: Best Practices to Protect the Donor and Recipient

“…Recent events in deceased organ donors (rabies, West Nile virus, balamuthia) considerably influenced the live organ donor workup and emphasized the importance of environmental exposure of the donor; however, given the very low prevalence of these infections and absence of widely available testing for some of these pathogens (e.g., balamuthia serology), universal donor screening would not be practical [22][23][24]29]. Furthermore, in the case of live donation, the time period between testing and donation should be taken into consideration as the transmissible disease may be contracted by a donor during this period.…”