Bacterial meningitis

and organ donation

Sally H Vitali, MD Chair, Organ Donation and Decedent Affairs Council and Oversight

Committee Boston Children’s Hospital

Poll Which of the following conditions is most likely to be a

contraindication to organ transplant?

A. Donor with viral encephalitis

B. Donor with bacterial meningoencephalitis

C. Donor with bacterial meningoencephalitis and

bacteremia

HPI Previously well 6 y/o girl had a headache and fever on

the afternoon of 2/3, kept home from school 2/4 with

frontal headache and fever. When afebrile was without

headache, playful and interactive.

2/5 playing with mom in the early morning and then

developed vomiting and unresponsiveness with GTC

seizures at 7:30 am.

Emergency Care Taken to urgent care where she had more seizures,

EMS called, gave diastat and took her to OSH ED.

At 11:15 am at OSH she was unresponsive with

nonreactive pupils. Intubated. Bilateral TMs dull,

possibly consistent with otitis media.

Investigations CT head at 11:45 am was repeated at 3:45 pm.

Rapid flu negative

CBC WBC count 9

Blood and urine cx sent, LP not performed

2/5

11:40 AM

Head CT

2/5

3:49 PM

Head CT

OSH

Imaging

Therapies at OSH Meningitic dosing of ceftriaxone

Hypertonic (3%) saline

Mannitol

Fosphenytoin

Exam @ BCH Intubated, comatose, pupils non-reactive

No reaction to painful stimuli, no gag

Neuroprotection

3% NaCl infusion for osmotherapy (targeting Na>145)

Dopamine as needed to target MAP 70-80 (assuming ICP>20 and desiring CPP 50-60)

Head of bed up at 30 degrees, maintained in midline

Ventilation with low PEEP and lowest PIP needed to achieve normocarbia

Normothermia

Seizure control

monitor Na, glucose, Osm

Other Therapies Broad-spectrum antibiotics at meningitic dosing

2/6 afternoon developed DI, remained on vasopressin

throughout rest of course

Brain MR 2/6 AM

Severe cerebral swelling

resulting in effacement of

the basal cisterns, cortical

sulci, quadrigeminal plate

cistern, and

cerebellopontine angles,

consistent with brain

herniation. The brainstem

is compressed and there is

inferior herniation of the

cerebellar tonsils into the

upper cervical spinal canal.

Brain MR 2/6 AM

There is hyper

accentuation of the

gray matter relative to

white matter,

consistent with global

anoxic injury.

Signal abnormality

seen along the

ependyma of the

ventricles is suggestive

of ventriculitis.

Brain MR 2/6 AM

There is no pathologic enhancement of the

leptomeninges or brain parenchyma. This is likely

related to diminished arterial (and gadolinium ) inflow.

MR Angiography 2/6 AM

The MRA of the circle of Willis demonstrates normal flow-related signal within the visualized common carotid arteries in the neck and diminished flow related signal within the internal carotid arteries to the level of the mid neck and no distal flow related signal intracranially.

Similarly, no flow related signal is seen within the vertebral arteries beyond approximately C2. Flow is present within the external carotid circulation.

Normal

MRA for

comparison

Etiology Blood cx from Wentworth Douglass grew Hemophilus

influenzae at 19.7 hours

NEOB evaluation Referred when met the clinical trigger per BCH policy:

“planning brain death testing”

Interested in CSF but willing to wait until after brain

death diagnosis and consent from family.

Brain death Family meeting after MRI 2/6 discussed brain death

testing the following day

1st brain death exam 8:45 am 2/7, 2nd brain death exam

5:45 pm 2/7. Both consistent with brain death. Na 140-

142, normothermic, and no sedatives on board.

Second family meeting 2/7 to inform family of brain

death diagnosis and discuss the option of organ

donation

NEOB Donor Management After donation consent, LP performed. Gram stain

abundant polys no organisms. Glucose 30, protein >200.

Donor antibiotics continued through procurement.

Blood, urine, CSF cultures resent 10 pm 2/7 and remained NG at ~36 hours at the time of procurement. Lab called just before cross-clamp in the OR for one final check

Levothyoxine infusion started around 9 pm 2/7 but stopped 6 am 2/8 for tachycardia and hypertension. Pressors were able to be weaned off with T4.

Lung resuscitation CXR 2/7 9 pm: Persistent left basilar opacity, likely

representing atelectasis.

Increased tidal volume from 7 cc/kg9 cc/kg, PRVC, PIP 18-20 throughout, PEEP 7

Bronchoscopy 2/8 03:44 with small amount of purulent secretions suctioned, malacic trachea near carina

CXR 2/8 10 am: Improved retrocardiac opacity, likely subsegmental atelectasis

Weaned PEEP to 5.

ABG: 7.37/41/174 on FiO2 0.4.

Donor CXR progression

2.7 9:24 pm 2.8 10:01 am

Donation outcome Heart, lungs, liver and kidneys were transplanted. The

heart and lung recipients were both boys under the age

of 10. Kidneys both went to women in their 50s and

liver went to a woman in her 60s.

Antibiotics were given to recipients based on donor

culture data provided to the transplant teams.

Donor-derived disease

transmission Infectious disease

Malignancy

• Viruses: Adenovirus (2), Hepatitis B virus (13), Hepatitis C virus (25), herpes

simplex, human immunodeficiency virus (HIV, 15), human T-lyphotrophic virus

(HTLV, 3), influenza (3), LCMV, parainfluenza (PIV)-3, parvovirus B19 (3),

rabies, West Nile virus (14).

• Bacteria: Acinetobacter (2), Brucella Enterococcus (including VRE), Ehrlichia

spp (2), E. coli, Gram Positive Bacteria, Klebsiella (2), legionella, listeria, Lyme

disease, nocardia, Pseudomonas (4), Rocky Mountain Spotted Fever, Serratia

(2), S. aureus (MRSA 2), Streptococcus spp, Syphilis (5) Veillonella; bacterial

meningitis and bacterial emboli.

• Fungus: Aspergillus spp (4), Candida spp (5), Coccidioides imitis (6),

Cryptococcus neoformans (5), Histoplasma capsulatum (6),zygomyces (5)

Ison et al. American Journal of Transplantation 2011; 11: 1123–1130

Donor-derived infectious diseases

OPTN “Guidance for Recognizing Central Nervous

System Infections in Potential Deceased Organ Donors:

What to Consider During Donor Evaluation and Organ

Offers”

There should be a “High index of suspicion for

meningoencephalitis as undiagnosed ME is very risky

for recipients.

OPOs should consider the following questions when

completing screening procedures for potential organ

donors.

Transplant Programs should also be aware of these

issues when considering organ offers.”

OPTN: Guidance for Recognizing Central Nervous System Infections in Potential

Deceased Organ Donors: What to Consider During Donor Evaluation and Organ Offers,

guideline revised 2/1/2014

Ruling out

meningoencephalitis (ME) • Donor age and cause of brain death. Children are less likely to

have strokes, infection more common in children. If cause is determined to be stroke, does the patient have comorbidities that make stroke likely or could it be ME?

Unexplained fever around presentation?

Altered mental status or seizures at presentation that could be evidence of ME?

CT, MRI, or LP evidence of infection?

Immunosuppressed host?

Environmental exposures to pathogens associated with ME? (e.g. WNV, tuberculosis, rabies)

OPTN: Guidance for Recognizing Central Nervous System Infections in Potential

Deceased Organ Donors: What to Consider During Donor Evaluation and Organ Offers,

guideline revised 2/1/2014

Reports of success with bacterially

infected donors

Meningoencephalitis and

Organ Donation…back to the poll

Bacterial meningoencephalitis not a contraindication

assuming that organism is identified as a susceptible

organism, treated appropriately, and CSF and blood (if

infected) sterilized. Recipients are treated with

antibiotics as well.

Viral meningoencephalitis (or strong suspicion of ME

with no cause identified) is a contraindication to

transplant, because it is more difficult/ impossible to

treat in the donor and the recipient and challenging to

prove the efficacy of the treatment.

Discussion? Questions? Thank you.