A Rare Case of Transfusion Transmission of Hepatitis A Virus to Two Patients with Haematological Disease

Abstract

Background: This paper describes the transmission of hepatitis A virus (HAV) to two blood recipients from a healthy donor that later presented to the blood bank with jaundice.

Methods: The RNA of HAV was detected by qualitative nested reverse transcription polymerase chain reaction (nested RT-PCR) and quantified by real-time RT-PCR. HAV RNA samples were genotyped by direct sequencing of PCR products. A sequence from a fragment of 168 bp from the VP1/2A HAV region was used to construct a phylogenetic tree.

Case report: A 31-year-old male donor accepted for donation of a whole blood unit returned to the blood bank with clinical jaundice 20 days after donation. His serological and NAT tests were negative for HBV and HCV. Serological tests for HAV IgM and IgG were negative on donation sample but positive on follow-up sample, confirming donor's HAV acute infection. Both recipients of red blood cells (R1) and platelet concentrate (R2) from the same implicated donation were HAV IgM-negative and IgG-positive. Qualitative PCR was positive on samples from all three individuals and phylogenetic analysis of viruses proved HAV transmission to the two recipients of blood products. HAV viral load on donor follow-up sample and the platelet recipient was 1.3 and 1.5 × 10(3) IU/ml, respectively. The RBC recipient, also infected by HCV, was undergoing bone marrow transplantation and died from fulminant hepatitis, 26 days after the implicated HAV transfusion.

Conclusion: The blood donor, a garbage collector, spontaneously returned to the blood bank when developing jaundice. This highlights the importance of donor education to immediately report to blood banks of any signs and symptoms related to infectious disease developed after blood donation. The fact that one immunocompromised patient with HCV infection died from fulminant hepatitis after receiving a HAV-contaminated platelet transfusion underpins the importance of a HAV vaccination program for these group of patients.

Keywords: Blood donor; Blood transfusion; Hepatitis A; Immunosuppression; Window period.

Fig. 1

Liver enzymes level of the R2 patient. ALT level (closed circles); ALT reverence level (41 U/l; dotted line); bilirubin levels (open circles); bilirubin reference level (1.1 mg/dl, dashed line).

Fig. 2

Detection of HAV RNA (VP1/2A genome). Nested RT-PCR products (247 bp) were visualized by 1.5% agarose gel and ethidium bromide staining. Lanes: (1) blood donor; (2) platelet recipient (R1); (3) RBC recipient (R2); (4) HAV-positive control; (5) negative control; (6) ØX 174 DNA ladder as molecular size standard.

Fig. 3

Phylogenetic tree of the three HAV isolates were constructed by neighbor-joining method and based on HAV 168 nucleotide (positions 3,024 to 3,191) in the VP1/2A region. Roman numerals designate the respective genotype groupings, whereas (A) and (B) designate subgenotypes. Bootstrap percentages were calculated from 2,000 replicates. The horizontal bar at the bottom represents an evolutionary distance of 0.05. Receptor 1 indicates platelet recipient (R1) and receptor 2 indicates RBC recipient (R2); HAV PC indicates positive control for HAV-nested RT-PCR. References sequences from GenBank included subgenotypes IA: HAS-15 (X15464), IB: HM-175 (M14707, Australia), and HAF-203 (AF26896, Brazil), IIA: CF-53 (L07693, France), IIB: (SLF88), and IIIA: Nor-21 (L07668). The sequences from Brazilian states: RJ (Rio de Janeiro), GO-348 (Goias) (AY322994), PA-315 (Pará) (AY322923), BA-301 (Bahia) (AY322898), has been reported by De Paula et al. [16].