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Malaria infection through multiorgan donation: an update from spain

Malaria Infection through Multiorgan Donation:
An Update From Spain

Monserrat Rodriguez,1 Santiago Tome,1 Luis Vizcaino,2 Javier Fernandez-Castroagudin,3
Esteban Otero-Anton,1 Esther Molina,3 Jorge Martinez,4 Gloria De la Rosa,5 Jose Lovo,6 and
Evaristo Varo
1Department of Internal Medicine, Complejo Hospitalario Universitario de Santiago, Santiago, Spain;
2Department of Biochemistry, Complejo Hospitalario Universitario de Santiago, Santiago, Spain;
3Department of Gastroenterology, Complejo Hospitalario Universitario de Santiago, Santiago, Spain;
4Department of Surgery, Complejo Hospitalario Universitario de Santiago, Santiago, Spain; 5Organizacio´n
Nacional de Trasplantes (ONT), Madrid, Spain;
6Department of Microbiology, Complejo Hospitalario
Universitario de Santiago, Santiago, Spain

During the last years, immigration has increased and, consequently, the pool of foreign donors and associated infectiousdiseases from exotic countries (especially from the tropics) has also increased. Only a few cases of malaria transmitted viadifferent donation sources have been published. In the present report, a Plasmodium vivax transmitted through a multiorgandonation is reported. In conclusion, we discuss the features related with the diagnosis, the treatment, and the specialcharacteristics of a case in which the liver and not any other organ is the reservoir of the plasmodium. Liver Transpl 13:1302-1304, 2007. 2007 AASLD.
Received February 25, 2007; accepted April 9, 2007.
Infectious diseases are an important cause of morbidi- transmitted via the hepatic allograft from a multiorgan ty-mortality after solid organ transplantation. They can arise from latent infections, “de novo,” or they can betransmitted from the donor. In recent years immigra- tion from tropical countries has increased progres-sively. As the pool of foreign donors has increased with A 30-yr-old male underwent orthotopic liver transplan- a corresponding increase in exotic infections, unusual tation because of hepatic acute failure due to the hep- infections such as human T-cell lymphotropic virus I atitis B virus. He received a graft from a 27-yr-old male and II, coccidiomycosis, histoplasmosis, blastomycosis, multiorgan donor who died as a consequence of spon- leishmaniasis, and malaria now represent a threat dur- taneous cerebral hemorrhage. The donor was born in Bolivia, had lived in Colombia, and had spent the last Malaria is not a common infection in transplant re- year of his life in Spain. He had malaria 3 yr ago and cipients. In fact, only a few cases have been reported underwent a successful malaria treatment, leaving him after kidney, liver, heart, and bone marrow transplants.
asymptomatic to the moment of his death. During the All species of Plasmodium causing human infection (P. organ donation process, a thick blood smear was per- falciparum, P. vivax, P. ovale, and P. malariae) can be formed with negative result. The lungs, heart, pan- transmitted by the graft. The outcome seems to be re- creas, and kidneys were transplanted to patients in lated not only to early diagnosis but also to prompt and The postoperative course was uneventful but on the In this work, a malaria case of Plasmodium vivax 21st posttransplantation day, the patient suddenly pre- Address reprint requests to Santiago Tome, Liver Unit, Department of Internal Medicine, Hospital clinico Universitario de Santiago, Choupana s/n15706, Santiago, Spain. Telephone: 34-981-951277; FAX: 34-981-950-622; E-mail: [email protected] DOI 10.1002/lt.21219Published online in Wiley InterScience (
2007 American Association for the Study of Liver Diseases.
MALARIA IN MULTIORGAN DONATION: AN UPDATE 1303 malaria developed were through renal grafts,4-6 al-though some cases of malaria had also been transmit-ted by liver,2,7-9 heart,2 and bone marrow grafts.10 Inthe liver transplant arena, only 5 cases have been welldocumented. One of them was a result of platelet trans-fusion and the others resulted from liver grafts. Theplasmodia species was identified in all cases. In 4 of thecases P. falciparum was the cause2,3,8,9 while P. vivaxwas the cause in the fifth case.7 As the donation wasmultiorgan, 2 patients developed malaria with graftsfrom sources other than the liver.2,7 Our patient had never traveled to an endemic malaria area. And on top of this, recipients from the same donorhave also developed malaria, which means the donorwas the origin of the disease. Therefore, in this case asin others,7 the disease resulted from an immunosup-pressed host due to the reactivation of plasmodia resid- Erythrocytes
ing in the liver donor. However in the cardiac, kidney, stained blood smear.
and lung recipients, the disease can only be explainedby subclinical and lower parasitemia in the donor.7 sented fever with chills and hypotension without an Effective differential diagnosis of infectious diseases apparent infectious origin. Broad spectrum antibiotic may be crucial in order to make a correct early diagno- treatment was begun with an unsuccessful outcome.
sis. The prognosis of a malaria case in a transplant The blood smear disclosed pancytopenia, hemolysis, patient seems to be influenced by the type of trans- and a high amount of intracellular parasites compatible planted organ, the plasmodium species, the immuno- with Plasmodium. The microbiological study confirmed suppressive treatment, and the delay in the onset of a P. vivax infection and it is important to note that antimalarial treatment.2 In kidney transplant cases, double parasitization was seen in the erythrocytes (Fig.
the clinical outcome may well be better than in liver or 1). A course of chloroquine (total dose: 1,500 mg) with cardiac transplantation; types of immunosuppression, primaquine (15 mg/day for 14 days, total dose: 210 mg) time of organ collection and ischemia time have been was started and the fever disappeared in 48 hours. At put forward as possible causes.2 There is also a corre- the same time the blood parasitization decreased con- lation between the degree of parasitemia and the sever- siderably after 48 hours. The tolerance to the medica- ity of the disease.2 Nevertheless, the main prognostic tion was moderately good without either liver or hema- factor is the ability to perform a rapid diagnosis and to deliver effective treatment.2 Serial measurements of Two months later the patient was admitted again with parasitemia together with clinical information are very a reappearance of the fever. A total of 80% of the eryth- useful.11 In the case reported here, the degree of para- rocytes were observed to have intracellular parasites.
sitization was considerable; however, the early treat- He received the same dose of chloroquine (total dose: ment led to a quick clinical and microbiological re- 1,500 mg) and a double dose of primaquine (30 mg/day for 14 days, total dose: 420 mg); the treatment schedule plasmodium as well as treating the acute phase, P. produced complete resolution of his condition and vivax and P. ovale required treatment with primaquine to eradicate any hypnozoite forms that may have re- A pancreas-kidney and lungs from the same donor mained dormant in the liver in order to prevent relaps- were transplanted into 2 different recipients. One yr es.11 Recent articles report P. vivax cases that were later, they did not develop malaria, the thick smears initially treated successfully with chloroquine and pri- were negative, and no treatment for malaria was given.
maquine and later suffered subsequent relapse due to Two additional patients who received heart and right primaquine tolerance. The use of doses higher than 15 kidney grafts were asymptomatic; however, as the thick ␮/day in order to prevent this risk has also been report- smears were positive they were treated and so far they ed.12 In the present case the immunosuppressive sta- tus as well as low doses of primaquine, and the fact theorgan in question was the liver and not any other, mightexplain why the patient relapsed. Nowadays the recom- mended treatment is a primaquine dose of 30 mg/day Malaria is a rare parasitic infection in patients who live or 0,5 mg/kg for 14 days, together with a schizonticidal outside of endemic zones. Although the mosquito’s bite drug (chloroquine or quinine) in the acute phase.13 or a reactivation of the latent disease are the common In the last years there has been a considerable in- mechanisms by which the disease is acquired in non- crease in the immigrant population, the number of for- compromised patients, in transplant patients, blood eign donors and the number of trips abroad. Because of transfusions or infected grafts are the most frequent this any immigrant or native donor who has traveled means of transmission.3 Most of the cases in which abroad, especially to tropical zones in the last 5 yr, LIVER TRANSPLANTATION.DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases should be tested for the most prevalent infections en- transfusion acquired malaria complicating orthotopic liver demic to each zone. A thorough screening is crucial transplantation. Am J Gastroenterol 1996;91:376-379.
because as with the case reported here, the donor may 4. Turkmen A, Sever MS, Ecder T, Yildiz A, Aydin AE, Erkoc R, et al. Posttransplant malaria. Transplantation 1996;62: be asymptomatic and, moreover, may have a negative thick blood smear simply as a result of lower para- 5. Nuesch R, Cynke E, Jost MC, Zimmerli W. Thrombocyto- sitemias. In the case of multiorgan donation, all recip- penia after kidney transplantation. Am J Kidney Dis 2000; ients should be screened as if they were asymptomat- ic.7 Today, there are no clear rules as to whether 6. Bemelman F, De Block K, De Vries P, Surachno S, Ten asymptomatic patients with negative thick blood Berge I. Falciparum malaria transmitted by a thick bloodsmear negative kidney donor. Scand J Infect Dis 2004;36: smears should receive preventive treatment or periodi- 7. Fischer L, Sterneck M, Costard-Jackle A, Fleischer B, In conclusion, malaria in the context of liver trans- Herbst H, Rogiers X, et al. Transmission of malaria terti- plantation continues to be a rare disease; however, as a ana by multi-organ donation. Clin Transplant 1999;:491- result of increased travel to endemic zones and of the increase in the number of immigrants as potential do- 8. Crafa F, Gugenheim J, Fabiani P, Di Marzo L, Militerno G, nors, we should be wary of uncommon infections that Iovine L, et al. Possible transmission of malaria by livertransplantation. Transplant Proc 1991;23:2664.
the recipients may acquire through transplant proce- 9. Menichetti F, Bindi ML, Tascini C, Urbani L, Biancofiore G, dures. Since the initial clinical picture is not always Doria R, et al. Fever, mental impairment, acute anemia, typical and it may lead to erroneous conclusions, accu- and renal failure in patient undergoing orthotopic liver rate early diagnosis in order to begin early treatment is 10. Lefrere F, Besson C, Datry A, Chaibi P, Leblond V, Binet JL, et al. Transmission of Plasmodium falciparum by allo-genic bone marrow transplantation. Bone Marrow Trans- 11. No authors listed. Parasitic infections. Am J Transplant 1. Angelis M, Cooper JT, Freeman RB. Impact of donor infec- tions on outcome of orthotopic liver transplantation. Liver 12. Baird JK, Hoffman SL. Primaquine therapy for malaria.
2. Chiche L, Lesage A, Duhamel C, Salame E, Malet M, 13. Centers for Disease Control and Prevention (CDC). Na- Samba D, et al. Posttransplant malaria: first case of trans- tional Center for Infectious Diseases, Division of Parasitic mission of Plasmodium falciparum from a white multior- Diseases. Treatment of Malaria (Guidelines For Clini- gan donor to four recipients. Transplantation 2003;75: cians). Available at: sis_treatment/tx_clinicians.htm. Last accessed: May 24, 3. Talabiska DG, Komar MJ, Wytock DH, Rubin RA. Post- LIVER TRANSPLANTATION.DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases


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