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

https://doi.org/10.1111/ajt.12726Get rights and content
Under a Creative Commons license
open archive

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 18 days posttransplantation presented with headache, ataxia and fever, followed by rapid neurologic decline and death. Diagnosis of granulomatous amebic encephalitis was made on autopsy. Balamuthia mandrillaris infection was confirmed with immunohistochemical and polymerase chain reaction (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, 1:64–1:512). Recipients received a four- to five-drug combination of miltefosine or pentamidine, azithromycin, albendazole, sulfadiazine and fluconazole. Nausea, vomiting, elevated liver transaminases and renal insufficiency were common. All other recipients survived and have remained asymptomatic 24 months posttransplant. This is the third donor-derived Balamuthia infection cluster described in solid organ transplant recipients in the United States. 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.

Key words:

Amebic encephalitis
Balamuthia mandrillaris
donor-derived infection
miltefosine

Abbreviations

CDC
Centers for Disease Control and Prevention
CSF
cerebrospinal fluid
FDA
Food and Drug Administration
GAE
granulomatous amebic encephalitis
HLF
human lung fibroblast
IFA
immunofluorescence assay
IHC
immunohistochemistry
OPO
organ procurement organization
OPTN
Organ Procurement and Transplantation Network
PCR
polymerase chain reaction
SOT
solid organ transplant

Cited by (0)

This work was presented in part at the American Society of Transplant Surgeon’s 13th Annual State-of-the-Art Winter Symposium, January 31–February 3, 2013, Miami, FL.