# Presentation: 776786

## WEST NILE VIRUS INFECTION IN SOLID ORGAN TRANSPLANT RECIPIENTS

**Deepali Kumar MD MSc FRCPC**
**Multi-organ Transplant & Infectious Diseases**
**University of Toronto, Canada**

## Case

**58 y.o. woman OLTx 2 years ago**** **
**Well since transplant;  On cyclosporin and MMF.**** **
**Not working; ++ outdoor activity / recent cottage visit (no protection measures). **** **
**Fever and chills then confusion and a headache.  **** **
**LP: WBC 58 mil/L and elevated protein (0.6 g/L). **

## Slide 3

## Hospital day 65

## Delayed Seroconversion

**WNV serology negative initially – positive 1 month later  **

## WNV in Transplantation

**WNV in Transplantation**

**Transplant patients can acquire WNV in 3 ways:****	**

**Transfusion-**
**transmitted**

**Organ **
**transmitted**

**Community-**
**acquired**

## WNV: TRANSFUSION TRANSMITTED

**23 cases of TTWNV (2002)**** **
**10 patients Immunocompromised (cancer,transplant)**
**2 patients were organ transplants (liver/kidney)**

**Pealer et al. NEJM, 2003**

## WNV: ORGAN DONOR TRANSMITTED

**Case with TTWNV, was an organ donor**
**2 kidneys**
**Liver**
**Heart**
**3 / 4 recipients meningoencephalitis**
**1 WNV fever **
**7-17 days post-transplant**
**1 death**

**Iwamoto et al., NEJM, 2003**

## Community-acquired WNV

| Case # | Tx | Serology | Presentation | Exposure |
| --- | --- | --- | --- | --- |
| 1 | Liver | IgM/IgG positive but delayed | Encephalitis | Cottage visit |
| 2 | Kidney | IgM/IgG positive | Encephalitis | Outdoor occupation |
| 3 | Heart | IgM/IgG positive
 | Meningitis | Outdoor occupation |
| 4 | Kidney | IgM/IgG positive
 | Encephalitis/
Flaccid paralysis | Cottage visit |

**Community-acquired WNV**

**Kumar et al. Transplantation, 2004**

## Community-acquired WNV

**28 cases in transplant patients in the literature**
**Majority have meningoencephalitis**** **
**What is the risk of neurologic disease in an organ transplant recipient?**

## A Seroprevalence Study of West Nile Virus in Solid Organ Transplant Recipients

**D Kumar, M Drebot, SJ Wong, G Lim, H Artsob, P Buck, A Humar**
**Infectious Diseases & Multi-organ Transplant, University of Toronto, Canada; National Microbiology Laboratory, Winnipeg; Centre for Infectious Disease Prevention and Control, Ottawa; New York State Dept. of Health, New York**

**Kumar et al. AJT, Nov.2004**

## USA WNV Meningoencephalitis 2002 

**USA WNV Meningoencephalitis 2002**** **

**CANADA – first ever WNV in 2002 – large epidemic in the Toronto Area **
**(~400 cases of mostly meningoencephalitis)**

## Community Acquired Seroprevalence

**Community Acquired Seroprevalence**

**Seroprevalence study of 816 organ transplant patients following the 2002 epidemic**
**All patients enrolled in Oct 2002; outpatients only **** **
**IgG, IgM testing, confirmed by PRNT**
**Questionnaire on knowledge and behavior patterns**
**This followed specific educational attempts by the transplant program in August and September**

## Outpatient serosurvey positive

| Case # | Tx | Serology | Presentation | Exposure |
| --- | --- | --- | --- | --- |
| 1 | Liver | IgM/IgG positive | Febrile illness/muscle weakness | Recreational outdoor activity |
| 2 | Liver | IgM/IgG positive | Febrile illness | Recreational outdoor activity |
| 3 | Kidney | IgM negative IgG positive | Asympt. | No exposures; foreign born |

**Outpatient serosurvey positive**

## Community Acquired WNV

**Community Acquired WNV**

**The seroprevalence of IgM antibody to West Nile was 2/816 (0.25%;95%CI 0.03-0.88%) **
**Based on application of the seroprevalence data to our population of ~ 2500 transplant patients, and using data from hospital based surveillance of meningoencephalitis...**

## Community Acquired WNV

**Community Acquired WNV**

**The estimated risk of meningoencephalitis in a transplant patient infected with WNV is 40% (95%CI 16-80%). **
**MUCH HIGHER RATE OF SEVERE DISEASE VS. GENERAL POPULATION (< 1%)**

## BEHAVIOUR PATTERNS

## Knowledge / Behaviors

## How can we prevent WNV transmission in transplantation?

**Blood screening**
**Careful donor screening**
**Clinical screening**
**LRDs: avoid high risk activities and use personal protection measures for 2 weeks prior to donation**
**OPTN does not currently recommend NAT testing**
**In our province, all donors are tested **

## How can we prevent WNV transmission in transplantation?

**Patient education**
**More severe disease in those on immunosuppression**
**Protection against mosquitoes**
**Reminder letter sent at the beginning of mosquito season**
**Vaccines?**
**Not live**