Doctors say a Michigan woman contracted Covid-19 and died last fall two months after receiving an infected double lung transplant from a donor who apparently contained the virus that causes the disease – although there were no signs of illness not and initially tested negative.
University of Michigan Medical School officials have suggested that this is the first proven case of Covid-19 in the US in which the virus was transmitted via an organ transplant. A surgeon who treated the donor lungs was also infected with the virus and became ill, but later recovered.
The incident appears to be isolated – the only confirmed case among nearly 40,000 transplants in 2020. But it has led to a call for more thorough testing of donors of lung transplants, with samples taken deep from the donor lungs as well as the nose and throat is. says Dr. Daniel Kaul, director of the service of Michigan Medicine’s Transplant Infectious Diseases.
All the performances we normally do and are able to do, we did.
“We would absolutely not have used the lungs if we had a positive Covid test,” Kaul said. He co-authored a report on the case in the American Journal of Transplantation.
The virus was transmitted when lungs of a woman from the Upper Midwest, who died after suffering a serious brain injury in a car accident, were transplanted into a woman with chronic obstructive pulmonary disease at the University’s Hospital in Ann Arbor. The nose and throat samples regularly collected from both organ donors and recipients were tested negative for SARS-CoV-2, the virus that causes Covid-19.
“All the performances we normally do and are able to do, we did,” Kaul said.
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Three days after surgery, however, the recipient picked fever; her blood pressure dropped and her breathing became difficult. Imaging showed signs of lung infection.
As her condition worsened, the patient developed problems with septic shock and heart function. Doctors decided to test for SARS-CoV-2, Kaul said. Samples of her new lungs returned positive.
‘A tragic case’
Doctors are suspicious about the origin of the infection and have returned to samples from the transplant donor. A molecular test of a swab from the donor’s nose and throat, taken 48 hours after her lungs were obtained, was negative for SARS-Cov-2. The donor’s family told doctors she had no history of recent travel or Covid-19 symptoms and no known exposure to anyone with the disease.
But doctors kept a sample of fluid washed deep into the donor lungs. When they tested the liquid, it was positive for the virus. Four days after the transplant, the surgeon who treated the donor lungs and performed the surgery also tested positive. Genetic screening showed that the transplant and the surgeon were infected by the donor. Ten other members of the transplant team tested the virus negatively.
The transplant recipient rapidly deteriorated and developed multisystem organ failure. Doctors have tried well-known treatments for Covid-19, including remdesivir, a newly approved drug and recovery plasma from people previously infected with the disease. Eventually, she was placed on the last option of ECMO, or extracorporeal membrane oxygenation. Life support was withdrawn, and she died 61 days after the transplant.
Kaul called the incident “a tragic case”.
While the Michigan case is the first confirmed incident in America to have been transmitted by a transplant, others are suspected. A recent Centers for Disease Control and Prevention report reviewed eight possible cases of what is known as a donor-derived infection that occurred last spring, but concluded that the most likely source of transmission of the Covid -19 virus in a community or health care was institution.
Prior to this incident, it was not clear whether the virus could be transmitted through solid organ transplants, although it has been well documented with other respiratory viruses. The spread of donors of H1N1 2009 pandemic flu has been detected almost exclusively in lung transplants, Kaul noted.
Extensive sampling required
While it is not surprising that SARS-CoV-2 can be transmitted through infected lungs, it remains uncertain whether other organs affected by Covid-19 – hearts, livers and kidneys – can also transmit the virus.
“It seems to non-lung donors that it can be very difficult to transfer Covid, even if the donor has Covid,” Kaul said.
Organ donors were regularly tested on SARS-CoV-2 during the pandemic, although not required by the Organ Procurement and Transplant Network, or OPTN, which oversees transplants in the US. But the Michigan case underscores the need for more extensive pre-transplant sampling, especially in areas with high Covid-19 transmission, Kaul said.
When it comes to lungs, this means testing samples from the lower airway of the donor as well as from the nose and throat. It can be difficult to obtain and test such samples from donors. There is also the risk of bringing infection into the donated lungs, Kaul said.
Because no organs other than lungs were used, the Michigan case does not provide insight into the testing of protocols for other organs.
In general, viral transmissions from organ donors to recipients remain rare, and they occur in less than 1 percent of transplant recipients, research shows. The medical risks faced by diseased patients who reject a donor organ are generally much higher, says Dr. David Klassen, chief medical officer of the United Network for Organ Sharing, the federal contractor that manages the OPTN.
“The risks of rejecting transplants are catastrophic,” he said. “I do not think patients should be afraid of the transplant process.”