The rabies virus causes a fatal encephalitis and can be transmitted through tissue or organ
transplantation. In February 2013, a kidney recipient with no reported exposures to potentially
rabid animals died from rabies 18 months after transplantation.
To investigate whether organ transplantation was the source of rabies virus exposure in the
kidney recipient, and to evaluate for and prevent rabies in other transplant recipients from the
Organ donor and all transplant recipient medical records were reviewed. Laboratory tests to
detect rabies virus–specific binding antibodies, rabies virus neutralizing antibodies, and
rabies virus antigens were conducted on available specimens, including serum, cerebrospinal fluid,
and tissues from the donor and the recipients. Viral ribonucleic acid was extracted from tissues and
amplified for nucleoprotein gene sequencing for phylogenetic comparisons.
Main Outcomes and Measures
Determination of whether the donor died from undiagnosed rabies and whether other organ
recipients developed rabies.
In retrospect, the donor’s clinical presentation (which began with vomiting and upper
extremity paresthesias and progressed to fever, seizures, dysphagia, autonomic dysfunction, and
brain death) was consistent with rabies. Rabies virus antigen was detected in archived autopsy brain
tissue collected from the donor. The rabies viruses infecting the donor and the deceased kidney
recipient were consistent with the raccoon rabies virus variant and were more than 99.9% identical
across the entire N gene (1349/1350 nucleotides), thus confirming organ
transplantation as the route of transmission. The 3 other organ recipients remained asymptomatic,
with rabies virus neutralizing antibodies detected in their serum after completion of postexposure
prophylaxis (range, 0.3-40.8 IU/mL).
Conclusions and Relevance
Unlike the 2 previous clusters of rabies virus transmission through solid organ transplantation,
there was a long incubation period in the recipient who developed rabies, and survival of 3 other
recipients without pretransplant rabies vaccination. Rabies should be considered in patients with
acute progressive encephalitis of unexplained etiology, especially for potential organ donors. A
standard evaluation of potential donors who meet screening criteria for infectious encephalitis
should be considered, and risks and benefits for recipients of organs from these donors should be