High Mortality Associated with Donor-Derived Coccidioidomycosis in a Population-Based Study of Potential Organ Donors in California

Background:

Unrecognized coccidioidomycosis (CI) transmitted via organ transplantation is potentially life-threatening. Given the wide variation in CI prevalence worldwide, there is limited guidance on which organ donors to test. There is also little information regarding CI-associated mortality on a transplant population level, which can be used to inform screening decisions.

Methods:

We conducted a retrospective cross-sectional study of all potential organ donors to Donor Network West (DNW, a large organ procurement organization) between Jan. 2014 and Feb. 2016. We determined CI prevalence by positive medical history, positive serology or organ biopsy. We obtained donor medical, social and demographic data from medical social history questionnaires. Recipient outcomes from all donors were analyzed. We compared survival in recipients with organs obtained from CI-infected and uninfected donors.

Results:

Eleven of 654 potential donors (1.7%) tested CI+. Of the 11 positive cases, 7 became actual donors, providing 26 organs for 22 recipients (3.7 organs/donor). Six of the 22 recipients (27.3%) died post-transplantation. Three of the 6 deceased recipients had definitive evidence of fungal infection and their deaths were likely related to CI transmission. Of the 643 non-infected potential donors, 600 actual donors provided 1,936 organs for 1,738 recipients (3.2 organs/donor). Seventy-eight of these recipients died post-transplant (4.5%). Compared to recipients from CI- organ donors, those who received organs from CI+ donors had higher mortality (OR 8.0, 95% CI 3.0-21.0, p<0.0001). Mean time between transplant and death did not differ between the CI- and CI+ groups (136 days vs. 99 days, p>0.20). Targeted screening of donors from endemic areas, with a history of incarceration, calcifications on chest imaging, or immunosuppression at the time of donation would have detected all CI+ donors.

Conclusion:

CI is rarely found in organ donors even from CI-endemic areas, but unrecognized CI can result in increased mortality in recipients. Targeted screening of donors will identify recipients who require CI prophylaxis, even in areas with low donor CI prevalence. This will likely improve patient safety and reduce CI-associated morbidity and mortality.