Portal de Periódicos da CAPES

SUCCESSFUL TRANSPLANTATION OF ORGANS RETRIEVED FROM A DONOR WITH SYPHILIS

1998; Wolters Kluwer; Volume: 65; Issue: 4 Linguagem: Inglês

10.1097/00007890-199802270-00029

1534-6080

Francisco Caballero, Peré Domingo, Núria Rabella, Antonio L pez-Navidad,

Hemoglobinopathies and Related Disorders

The availability of cadaveric organs is the most important factor limiting the number of transplants performed worldwide. The paucity of organ donation, in view of the increasing demand, makes each additional available organ important because it is known that a significant number of potential recipients die while they are still on the waiting list(1). These facts have prompted changes in the donor criteria to accept cadaveric organs previously considered unacceptable. This has been the case when potential organ donors have died because of bacterial meningitis (2), when donors have ischemic injured kidneys, and in donors with early diabetes (3). We have recently cared for a patient with late syphilis who had brain death due to intracerebral hemorrhage. Their organs were transplanted into three recipients. None of the recipients had clinical or serologic evidence of syphilis. A 63-year-old woman was admitted to the hospital because of thrombophlebitis of the right leg and right tibial fracture. Therapy with heparin (5 mg/kg) was started upon admission. A neurological examination disclosed Argyll-Robertson pupils, absent knee and ankle jerks, and loss of vibratory sense on both legs. An electromyogram was normal. The rapid plasma reagin (RPR) test was negative, but the hemagglutination assay forTreponema pallidum (HATP) was positive (++++). The patient had an intracerebral hemorrhage on her 12th hospital day that quickly evolved to brain death. Evaluation as an organ donor included renal and liver function tests, chest roentgenogram, electrocardiogram, echocardiogram, and abdominal ultrasound examination, and all were normal. Treatment with ceftriaxone was done for 28 hr before retrieval of the kidneys, liver, and heart. Postmortem examination disclosed a temporoparietal hemorrhage without additional encephalic or meningeal findings. No gummas were found, but there was a chronic polygangliorradiculoneuritis. The right kidney was transplanted into a 50-year-old woman with end-stage renal failure due to diabetic nephropathy. She received cyclosporine and prednisone, and 18 million units of penicillin a day for 10 days. At 16 months after transplantation, her creatinine level was 150 μmol/L, there were no clinical symptoms of syphilis, and RPR and HATP were repeatedly negative. The left kidney could not be transplanted because of renal vein thrombosis. The liver was transplanted into a 60-year-old woman with liver cirrhosis due to hepatitis C virus. She had a primary graft failure and had a second liver transplant. Pathologic examination of the liver graft showed an extensive ischemic centrolobulillar necrosis and suprahepatic vein thrombosis. RPR and HATP have been negative to date. The heart was transplanted into a 57-year-old woman. She received 18 million units of penicillin a day for 10 days. The immediate posttransplant period was complicated by renal failure, acute polineuropathy, subacute cholangitis, and pancreatitis. She died 4 months after transplantation because of severe sepsis with multiorgan failure. There were no clinical symptoms or signs of syphilis, and both reaginic and treponemic tests were repeatedly negative. Presently, direct experience with iatrogenic transmission of syphilis is limited to early blood banking and human experimentation(4, 5). There have been no reported cases of syphilis transmission by organ transplantation to date. However, the risk of syphilis in organ donors is not negligible, and it has been estimated to be about 0.15% (6). Fortunately, the risk of transmitting syphilis by organ transplantation is further lowered by the frequent use of penicillin in perfusion solutions and by the low temperature at which organs are stored, thereby causing inactivation of T pallidum(7). The criteria used for approaching an organ donor with a positive syphilis serology are controversial. Although some centers specifically exclude organ donors with syphilis, others exclude only donors with evidence of generalized infection and do not consider inactive syphilis an absolute contraindication for organ retrieval (6). There has been only one reported case of successful kidney transplantation from a patient with serologic evidence of syphilis. Both recipients received penicillin therapy and did not develop serologic evidence for syphilis. Our donor definitely had late syphilis as evidenced by a clinical neurologic examination, Charcot's joint, serology, and postmortem examination of the spinal ganglia. Treatment of donor and recipients with treponemicidal antibiotics prevented transmission of syphilis. Thus, based on the report by Gibel et al. (6) and our own experience, we think that the use of serologically positive donors, once structural lesions in potentially transplantable organs have been thoroughly ruled out, is justifiable if syphilis has been adequately treated in the donor and treponemicidal antibiotic prophylaxis is administered to the recipients. In addition, screening for syphilis in organ donors must include both reaginic and treponemic tests because reaginic tests may be negative in more than 40% of patients with late syphilis, whereas HATP and fluorescein treponema antibodies have a sensitivity of 95% in these patients(8). In the exceedingly rare cases in which both tests are negative but in which syphilis still is a possible diagnosis, the detection of DNA of T pallidum by polymerase chain reaction may be a useful adjunct to the diagnosis (9). Francisco Caballero Pere Domingo1 Nuria Rabella Antonio López-Navidad Transplant Coordination Unit; Departments of Internal Medicine and Microbiology; Hospital de la Santa Creu i Sant Pau; Universitat Autònoma de Barcelona; 08025 Barcelona, Spain