This week’s issue of The New England Journal of Medicine carries a paper describing previously reported cases of fatal rabies infection in patients who received organs and tissue from a single infected donor, marking the first time rabies has been spread through solid organ donation.

The outbreak was first reported by the Centers for Disease Control and Prevention last July. This week’s update includes the discovery of a fourth patient - in addition to the three originally reported - who acquired the infection after receiving a blood vessel graft from the donor.

“This has never happened before,” Dr. Mitchell Cohen, director of the coordinating center for infectious diseases at the CDC, told reporters at a media briefing last year. “Human rabies is very rare - we see only a few human cases each year and it is usually in people who have been bitten or scratched by bats. The risk of healthcare-associated transmission is considered to be extremely low.”

Although there have been reports of rabies transmission through cornea transplants, this is the first report of transmission from solid organ transplantation, according to the CDC.

The rabies infections originated from a previously healthy male Arkansas resident who was seen at an emergency room in Texas because of neurological symptoms and fever. Brain scans revealed a hemorrhage and the patient died 48 hours later.

Routine donor eligibility testing revealed no obstacles to organ transplant and his family gave consent for donation. Rabies testing is not currently part of the screening procedure.

The donor’s kidneys, liver, and a blood vessel segment were transplanted into four patients in May 2004. The recipient patients were hospitalized with symptoms of low blood pressure, seizures, and lethargy within 30 days of transplantation, and all four died an average of 13 days after the onset of neurological symptoms.

A series of tests were performed on the recipients and the CDC confirmed that all four were infected with a strain of rabies commonly found in bats. Prior to his death, the donor had apparently told his friends of being bitten by a bat.

“This rabies outbreak was really picked up because you had patients who were in close proximity within the same healthcare system,” Dr. Arjun Srinivasan, lead author of the journal report, told Reuters Health. “The same physician saw more than one of these patients and was able to put things together.”

“Improving dialog between centers or even across states, through the organ procurement organizations, may go a long way toward detecting these sorts of clusters sooner,” Srinivasan, from the Atlanta-based CDC, added.

SOURCE: The New England Journal of Medicine, March 17, 2005.