A woman in Michigan died 61 days after receiving a pair of lungs from an organ donor who had been infected with the coronavirus, according to a case report published this month.
There was no indication that the donor, a woman fatally injured in a car accident, had Covid-19. An X-ray of his chest looked clear and a nasal smear test for the coronavirus returned a negative result.
But doctors who worked with the lung receiver at University Hospital in Ann Arbor, Michigan, last fall, began to question these results when their patients’ condition worsened. They concluded that the donor did indeed have Covid-19 – and that his lungs had infected not only the transplant patient, but also the surgeon.
It was the first confirmed case of a patient contracting the virus from an organ donor, according to the authors of the peer-reviewed report, published in The American Journal of Transplantation on February 10.
“We want the transplant community to be aware that this can happen, and also that there may be things we can do to improve our success in screening patients for Covid,” said the surgeon, Dr. Jules Lin, author of the report and the surgical director of the Michigan Medicine lung transplant program, the University of Michigan health care system.
The report said medical professionals should consider testing lung donors for the coronavirus using a sample from their lower respiratory tract, which extends to the lungs – beyond the reach of a nasal swab. This type of test, which is invasive and not recommended for the general public, is not always available; currently, only about a third of donated lungs are tested in this way.
Dr. David Klassen, medical director of the United Network for Organ Sharing, the nonprofit organization that administers the country’s organ transplant system, said the Michigan case was “very significant”, despite its rarity.
“We want to minimize any chance of this happening again,” he said.
Every organ donor in the United States is tested for coronavirus in some way, said Dr. Klassen. Tests are not conducted by transplant surgeons; instead, they are usually overseen by nonprofit groups known as organ procurement organizations, which operate in the United States.
The Association of Organ Procurement Organizations referred the questions to Gift of Life Michigan, which was not involved in this case. Its clinical director, Bruce Nicely, said many laboratories refused to analyze samples from the lower lungs at the beginning of the pandemic, fearing that the procedure could contribute to the spread of the coronavirus.
“In response to the study’s recommendations, we all support recommendations that improve safety and reduce the risk of infection,” said Nicely, adding that her organization found a laboratory partner capable of performing lower respiratory tract testing.
When organs are available, time is of the essence. Some health facilities lack the resources to quickly test donors’ lower respiratory tract for Covid-19. Given these restrictions, there is no requirement that lung donors be tested in this way.
“We could demand that,” said Klassen. “But it can have the effect of severely limiting the lungs that can be used for transplants.”
Of the nearly 40,000 organ transplants performed in the United States last year, the Michigan operation was the only confirmed case of a recipient contracting a donor’s coronavirus.
“It is important to emphasize that this is, fortunately, a rare event,” said Dr. Daniel R. Kaul, author of the study and an infectious disease specialist at Michigan Medicine. The case, he said, should not dissuade people from having transplants that can save their lives.
He added that the organ recipient, who suffered from chronic obstructive pulmonary disease, appeared to have been operated on successfully until his condition worsened a few days later.
“Suddenly, she had a fever, low blood pressure and pneumonia,” said Kaul. “I wasn’t sure what was going on.”
When new tests showed that the woman had Covid-19, doctors examined the lung donor. His nasal smear test had been negative before the transplant, but these tests do not take everything. Doctors needed to find a way to test the donor again.
In the end, they had exactly what they needed: a sample of the deceased’s lower respiratory tract. Michigan Medicine regularly collects these samples from lung donors to test them – not for Covid-19, but for ureaplasma, a bacterium that can cause a rare syndrome.
The doctors found that they still had enough donor samples to test for the coronavirus. The result showed that the donor had indeed been infected with the virus, and analysis of the gene sequence showed that the patient had contracted the virus from the donor’s lungs.
The same happened with Dr. Lin, who was wearing a surgical mask during the transplant operation. (The report he co-wrote recommends that transplant centers consider the benefits of wearing N95 masks during the hour-long procedure, even if the donor tested negative for the coronavirus.) He spent a few weeks recovering from the infection in home, he said, adding that the infection did not spread to his colleagues or family.
The patient, vulnerable after a major operation, did not recover, despite doctors’ attempts to save her with a series of treatments, including convalescent plasma, steroids and remission. Doctors now hope that their case report will convince more medical professionals to strengthen their standards for coronavirus testing for organ donors, despite logistical difficulties.
“I think these are barriers that we have to work on to overcome,” said Dr. Lin, “for the safety of our patients.”