On January 27, 2025, CDC was notified of possible rabies virus infection in a kidney transplant recipient. After CDC confirmed diagnosis, jurisdictional health departments and CDC conducted an investigation to determine the source of the infection and to identify other persons at risk.
Kidney Recipient
In December 2024, an adult male Michigan resident received a left kidney transplant from an Idaho donor at an Ohio hospital. Approximately 5 weeks later, the recipient experienced tremors, lower extremity weakness, confusion, and urinary incontinence. Seven days after symptom onset, he was hospitalized with fever, hydrophobia, dysphagia, and autonomic instability. On hospital day 2, he required invasive mechanical ventilation. On hospital day 4, clinicians consulted the Ohio Department of Health and CDC because the recipient’s signs and symptoms were compatible with rabies. The Donor Risk Assessment Interview (DRAI) questionnaire reported that the donor had received a skunk scratch. The kidney recipient’s saliva, nuchal skin biopsy, serum, and cerebrospinal fluid samples, collected on hospital days 3–6, were sent to CDC for rabies testing. On hospital day 7, the recipient died; postmortem brain tissue samples were sent to CDC. Rabies virus RNA was detected in saliva, nuchal skin, and brain tissue samples. Rabies virus immunoglobulin (Ig) M, IgG, and neutralizing antibodies were detected in serum. Viral characterization was consistent with the silver-haired bat (Lasionycteris noctivagans) rabies virus variant. Michigan public health officials interviewed the kidney recipient’s family; no animal exposures were reported.
Idaho Organ Donor
After rabies was suspected, the Idaho Department of Health and Welfare, the local public health district, and CDC investigated the Idaho donor as the possible infection source. Interviews with the family added details not included in the DRAI questionnaire. In late October 2024, a skunk approached the donor as he held a kitten in an outbuilding on his rural property. During an encounter that rendered the skunk unconscious, the donor sustained a shin scratch that bled, but he did not think he had been bitten. According to the family, the donor attributed the skunk’s behavior to predatory aggression toward the kitten.
A member of the donor’s household reported that approximately 5 weeks later, in early December, the donor was confused, had difficulty swallowing and walking, experienced hallucinations, and had a stiff neck. Two days after symptom onset, he was found unresponsive at home after presumed cardiac arrest. He was resuscitated and hospitalized but never regained consciousness. He was declared brain dead and removed from life support on hospital day 5. Left kidney, heart, lungs, and both corneas were recovered.
After rabies was suspected in the kidney recipient, stored serum that had been collected from the donor on his third hospital day was tested and determined to be negative for rabies virus antibody. A multiweek laboratory traceback investigation identified right and left kidney biopsy samples. CDC detected rabies virus RNA consistent with a silver-haired bat rabies virus variant in a biopsy sample of the right kidney, suggesting organ-derived transmission. The left kidney biopsy sample had insufficient tissue for testing.
Donor Corneal Tissues and Tissue Recipients
Four ocular grafts were prepared from recovered corneas. Three patients, one each from California, Idaho, and New Mexico, received grafts in December 2024 and January 2025. While investigation of the donor’s rabies status was ongoing, the cornea recipients underwent precautionary graft removal and received PEP. They remained asymptomatic. A planned transplantation of the fourth corneal graft to a Missouri patient was cancelled. CDC detected rabies virus RNA consistent with a silver-haired bat rabies virus variant in one previously implanted corneal graft.
Donor Heart and Lungs
The heart and lungs of the donor were not transplanted but were used in training procedures at a Maryland medical research facility. By the time of the public health investigation, no specimens were available for testing.
Rabies Risk Assessments and PEP Recommendations
Rabies virus detection in the kidney recipient prompted investigations to identify persons who were exposed to either the presumed rabid skunk, the donor, or the kidney recipient during their respective infectious periods. Rabies virus can be transmitted via direct contact of saliva, tears, or innervated tissues (e.g., organs and other body tissues) from infected humans or animals with broken skin or mucous membranes. Infectious periods were defined as 14 days before symptom onset until death and decontamination. Public health officials, agency medical directors, and occupational health staff members conducted exposure risk assessments to determine which contacts should consult their provider to receive the appropriate PEP course. Data on the percentage of contacts recommended PEP who received it were unavailable.
Persons exposed to donor and skunk. No other persons or animals were exposed to the presumed rabid skunk. Four community contacts were identified and completed risk assessments; all were recommended to receive PEP. An additional 80 health care worker contacts were identified and completed risk assessments; (21%) were recommended to receive PEP. The three cornea recipients received PEP, consisting of human rabies immunoglobulin and 4 rabies vaccine doses, and antibody testing to confirm adequate vaccination responses.
Persons exposed to kidney recipient. Fourteen community contacts were identified and completed risk assessments; six were recommended to receive PEP. An additional 269 health care worker contacts were identified, 256 (95%) of whom completed risk assessments; 16 (6%) were recommended to receive PEP.
If you or a loved one suffered serious injury or other harms as a result of medical negligence involving an organ transplant in the United States, you should promptly consult with a transplant malpractice lawyer in your state who may investigate your transplant malpractice claim for you and represent you in a medical malpractice transplant case, if appropriate.
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