Outcomes in solid organ transplant recipients receiving organs from a donor with Fusarium solani species complex meningitis

Abstract

Background: Five organs (heart, right lung, liver, right, and left kidneys) from a deceased patient were transplanted into five recipients in four US states; the deceased patient was identified as part of a healthcare-associated fungal meningitis outbreak among patients who underwent epidural anesthesia in Matamoros, Mexico.

Methods: After transplant surgeries occurred, Fusarium solani species complex, a fungal pathogen with a high case-mortality rate, was identified in cerebrospinal fluid from the organ donor by metagenomic next-generation sequencing (mNGS) and fungal-specific polymerase chain reaction and in plasma by mNGS.

Results: Four of five transplant recipients received recommended voriconazole prophylaxis; four were monitored weekly by serum (1-3)-β-d-glucan testing. All five were monitored for signs of infection for at least 3 months following transplantation. The liver recipient had graft failure, which was attributed to an etiology unrelated to fungal infection. No fungal DNA was identified in sections of the explanted liver, suggesting that F. solani species complex did not contribute to graft failure. The remaining recipients experienced no signs or symptoms suggestive of fusariosis.

Conclusion: Antifungal prophylaxis may be useful in preventing donor-derived infections in recipients of organs from donors that are found to have Fusarium meningitis.

Keywords: fungal meningitis; fusarium.

FIGURE 1

Clinical and selected laboratory findings in the organ donor and five organ transplant recipients, 2023. For recipients, weekly Fungitell (1–3)-β-d-Glucan (BDG) of serum. POS indicates positive BDG results, NEG indicates negative results, and ND indicates no BDG testing preformed. For organ donor, tests for infection consisted of mNGS of donor CSF and plasma, as well RT-PCR of donor CSF. Donor results are based on report date of results (not date of collection). Abbreviations: PNF, Primary nonfunction; mNGS, metagenomic next-generation sequencing; BDG, Fungitell (1–3)-β-d-Glucan; CSF, cerebrospinal fluid; PCR, polymerase chain reaction. Week 1 includes days 0–6.

FIGURE 2

Metagenomic next-generation sequencing (mNGS) laboratory findings in the organ donor. (A) Heat maps generated from the SURPI+ bioinformatics pipeline. Each column corresponds to a CSF or plasma sample, and the rows correspond to a taxonomic designation at the species level. The rows are ranked by number of reads, and the cells are color-coded, with the highest number of reads in red, fewer reads in green, and 0 reads in gray. Note that Nectria haematococca is the sexual anamorph of Fusarium solani. Abbreviations: RPM(pp), reads per million preprocessed reads. The asterisk denotes rows for which the detected fungal reads have been “declassified” because they are not specific at the species level. (B) Mapping of plasma mNGS reads identified as Nectria haematococca (58 and 36 reads) to their chromosomal locations in the Fusarium solani genome. * Denotes rows for which the detected fungal reads have been “declassified” because they are not specific at the species level.¹¹