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Man’s health crashes after getting donated kidney [arstechnica.com]:

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About two months after receiving a donated kidney, a 61-year-old man ended up back in the hospital. He was tired, nauseous, and vomiting. He was also excessively thirsty and producing too much urine. Over the next 10 days, things only got worse. The oxygen levels in his blood began to fall. His lungs filled with fluid. He kept vomiting. He couldn't eat. Doctors inserted a feeding tube. His oxygen levels and blood pressure kept falling. He was admitted to the intensive care unit and put on mechanical ventilation. Still, things kept getting worse.

At that point, he was transferred to the ICU of Massachusetts General Hospital, where he had received the transplant. He was in acute respiratory failure and shock.

In a case report in this week's issue of the New England Journal of Medicine [nejm.org], doctors at Mass General explained how they determined what was wrong with the man. Their first steps were collecting more information about the man's symptoms from his wife, reviewing his family medical history, and contacting the regional organ-procurement organization that provided the kidney.

Process of elimination

The man's condition and laboratory tests suggested he had some sort of infection. But as a transplant recipient who was on a variety of immunosuppressive drugs, the list of infectious possibilities was "extensive."

Dr. Camille Kotton, Clinical Director of the hospital's Transplant and Immunocompromised Host Infectious Diseases division, laid out her thinking. She started with a process of elimination. As an immunosuppressed transplant patient, he was also on several medications to proactively prevent infections. These would rule out herpesviruses and cytomegalovirus. He was also on a combination of antibiotics that would rule out many bacterial infections, as well as the fungal infection Pneumocystis jirovecii [nih.gov] that strikes the immunocompromised and the protozoan parasite Toxoplasma gondii [nih.gov].

One feature stood out: The man had developed elevated levels of eosinophils, white blood cells that can increase for various reasons—including parasitic infections. The man also had a reddish-purple rash over his abdomen. Coupled with the severity of his illness, Kotton suspected a widespread parasitic infection.

The man's history was notable for contact with domestic cats and dogs—including a cat scratch in the time between having the transplant and falling critically ill. But common bacterial infections linked to cat scratches could be ruled out. And other parasitic infections that might come from domestic animals in the US, such as toxocariasis, don't typically lead to such critical illnesses.

Kotton began to suspect Strongyloides [cdc.gov], a parasitic roundworm that infects the gastrointestinal tract. It spreads from dogs [cdc.gov] in tropical regions. In most people, the infection is unnoticeable. But in the immunosuppressed, it can cause a deadly hyperinfection syndrome [nih.gov], with the worms going through accelerating and uncontrolled life cycles and spreading throughout the body, including the liver, brain, lymph nodes, and skeletal muscles.

A missing test

Kotton called the organ-procurement organization and found the deceased donor was from the Caribbean—where Strongyloides are present. The donor had not been tested for the infection before the transplant. But blood samples on record were subsequently tested and found to have antibodies against the parasite, suggesting an infection. The transplant patient's pre-transplant blood samples, on the other hand, were negative.

Doctors at Mass General began tests, which revealed worms and worm larvae in the man's lungs and stool. A skin punch also found worms—the man's abdominal rash was caused by the worms meandering through his skin.

Treating such a widespread worm infection is challenging. The extensive infection would ideally be combated by intravenous delivery of a powerful anti-parasitic. But the treatment for strongyloidiasis is the deworming drug ivermectin, which is only approved by the Food and Drug Administration for oral formulations in humans. But gastrointestinal absorption of the drug can be thwarted by GI troubles, which the man had.

Given the patient's grave condition, the doctors obtained special approval to deliver ivermectin subcutaneously—a delivery method otherwise used only in veterinary medicine—as well as orally. They also got a message from another hospital: The person who had gotten the donor's other kidney was critically ill. The doctors shared notes.

In the end, both patients recovered, and the doctors were left trying to figure out how this could have happened. A 2021 report [nih.gov] from the Organ Procurement and Transplantation Network found that the overall risk of getting a donated organ with any infection was 0.14 percent. Still, of the very small number of cases of parasites spreading from donated organs, 42 percent were due to Strongyloides. In 2023, the United Network for Organ Sharing updated its policy to recommend universal screening for Strongyloides [unos.org].

i-was-told-ivermectin-is-only-for-horses dept.

Journal Reference:
Just a moment..., (DOI: https://www.nejm.org/doi/full/10.1056/NEJMcpc2412510 [doi.org])

Original Submission