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

摘要

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.