title: Raccoon rabies virus variant transmission through solid organ transplantation.
abstract: OBJECTIVE
  The rabies virus causes a fatal encephalitis and can be transmitted through tissue or organ transplantation. In February 2013, a kidney recipient with no reported exposures to potentially rabid animals died from rabies 18 months after transplantation.
  
  
  OBJECTIVE
  To investigate whether organ transplantation was the source of rabies virus exposure in the kidney recipient, and to evaluate for and prevent rabies in other transplant recipients from the same donor.
  
  
  METHODS
  Organ donor and all transplant recipient medical records were reviewed. Laboratory tests to detect rabies virus-specific binding antibodies, rabies virus neutralizing antibodies, and rabies virus antigens were conducted on available specimens, including serum, cerebrospinal fluid, and tissues from the donor and the recipients. Viral ribonucleic acid was extracted from tissues and amplified for nucleoprotein gene sequencing for phylogenetic comparisons.
  
  
  METHODS
  Determination of whether the donor died from undiagnosed rabies and whether other organ recipients developed rabies.
  
  
  RESULTS
  In retrospect, the donor's clinical presentation (which began with vomiting and upper extremity paresthesias and progressed to fever, seizures, dysphagia, autonomic dysfunction, and brain death) was consistent with rabies. Rabies virus antigen was detected in archived autopsy brain tissue collected from the donor. The rabies viruses infecting the donor and the deceased kidney recipient were consistent with the raccoon rabies virus variant and were more than 99.9% identical across the entire N gene (1349/1350 nucleotides), thus confirming organ transplantation as the route of transmission. The 3 other organ recipients remained asymptomatic, with rabies virus neutralizing antibodies detected in their serum after completion of postexposure prophylaxis (range, 0.3-40.8 IU/mL).
  
  
  CONCLUSIONS
  Unlike the 2 previous clusters of rabies virus transmission through solid organ transplantation, there was a long incubation period in the recipient who developed rabies, and survival of 3 other recipients without pretransplant rabies vaccination. Rabies should be considered in patients with acute progressive encephalitis of unexplained etiology, especially for potential organ donors. A standard evaluation of potential donors who meet screening criteria for infectious encephalitis should be considered, and risks and benefits for recipients of organs from these donors should be evaluated.
authors.affiliation: Poxvirus and Rabies Branch, Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.
authors.forename: Neil M
authors.initials: NM
authors.lastname: Vora
authors.forename: Sridhar V
authors.initials: SV
authors.lastname: Basavaraju
authors.forename: Katherine A
authors.initials: KA
authors.lastname: Feldman
authors.forename: Christopher D
authors.initials: CD
authors.lastname: Paddock
authors.forename: Lillian
authors.initials: L
authors.lastname: Orciari
authors.forename: Steven
authors.initials: S
authors.lastname: Gitterman
authors.forename: Stephanie
authors.initials: S
authors.lastname: Griese
authors.forename: Ryan M
authors.initials: RM
authors.lastname: Wallace
authors.forename: Maria
authors.initials: M
authors.lastname: Said
authors.forename: Dianna M
authors.initials: DM
authors.lastname: Blau
authors.forename: Gennaro
authors.initials: G
authors.lastname: Selvaggi
authors.forename: Andres
authors.initials: A
authors.lastname: Velasco-Villa
authors.forename: Jana
authors.initials: J
authors.lastname: Ritter
authors.forename: Pamela
authors.initials: P
authors.lastname: Yager
authors.forename: Agnes
authors.initials: A
authors.lastname: Kresch
authors.forename: Mike
authors.initials: M
authors.lastname: Niezgoda
authors.forename: Jesse
authors.initials: J
authors.lastname: Blanton
authors.forename: Valentina
authors.initials: V
authors.lastname: Stosor
authors.forename: Edward M
authors.initials: EM
authors.lastname: Falta
authors.forename: G Marshall
authors.initials: GM
authors.lastname: Lyon
authors.forename: Teresa
authors.initials: T
authors.lastname: Zembower
authors.forename: Natalia
authors.initials: N
authors.lastname: Kuzmina
authors.forename: Prashant K
authors.initials: PK
authors.lastname: Rohatgi
authors.forename: Sergio
authors.initials: S
authors.lastname: Recuenco
authors.forename: Sherif
authors.initials: S
authors.lastname: Zaki
authors.forename: Inger
authors.initials: I
authors.lastname: Damon
authors.forename: Richard
authors.initials: R
authors.lastname: Franka
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Kuehnert
mesh_terms: D000818:Animals; D006801:Humans; D055256:Infectious Disease Incubation Period; D016030:Kidney Transplantation / Q000009:adverse effects*; D008297:Male; D016133:Polymerase Chain Reaction; D011818:Rabies / Q000175:diagnosis / Q000503:physiopathology / Q000517:prevention & control / Q000635:transmission*; D011819:Rabies Vaccines / Q000627:therapeutic use; D011820:Rabies virus / Q000235:genetics* / Q000302:isolation & purification; D011821:Raccoons / Q000821:virology; D012189:Retrospective Studies; D014019:Tissue Donors
chemical_list: D011819:Rabies Vaccines
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