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Background Human adenovirus (HAdV) infections can lead to high mortality in solid organ transplant (SOT) recipients, with rare reports of donor-derived infection. Methods Two renal transplant recipients with HAdV-11 infection who received kidneys from the same donor are described. Whole-genome sequencing (WGS) was performed. Results WGS showed 100% nucleotide sequence identity for the 2 HAdV-11 isolates. The patients presented with distinct clinical syndromes, and both were treated with brincidofovir. Conclusions Donor-derived HAdV infection is presumed to be low; however, disseminated HAdV in SOT recipients can be severe, and clinicians should be aware of the clinical course and treatment options.

Human adenovirus type 34 (HAdV-34) infection is a recognized cause of transplant-associated hemorrhagic cystitis and, in rare cases, tubulointerstitial nephritis. The source of such infections is often difficult to assess, that is, whether acquired as a primary infection, exposure to a pathogen in the transplanted organ, or reactivation of an endogenous latent infection. We present here 2 cases of likely transplant-acquired HAdV-34 infection from the same organ donor, manifesting as tubulointerstitial nephritis in 1.

Background Donor derived Mycobacterium tuberculosis (DDTB) has occasionally been reported after solid-organ transplantation (SOT). Methods To characterize DDTB, MEDLINE OVID, and EMBASE were reviewed from inception to December 31, 2016 using key words donor-derived infection, tuberculosis and solid-organ transplant. Results A total of 36 cases of proven (17), probable (8) and possible (11) DDTB were identified among 16 lung, 13 kidney, six liver, and one heart recipient. Most patients were male (21/35, 60%); median age was 48 (range 23–68) years. Median time to DDTB was 2.7 (0.2–29) months after SOT. Donor residence in TB-endemic area (13/28, 46.4%) was common. Fever was the most frequent symptom (20/36, 56.5%). DDTB was classified as pulmonary (36%), extra-pulmonary (28%) or disseminated (36%), with common involvement of the allograft (31/36, 86%). Diagnosis was made by smear or culture (30/36, 83.3%). Three (10/24, 41.7%) or four-drug therapy (13/24, 54.2%) was given for median of 10.5 (range, 6–24) months. Graft loss, all-cause and TB-attributable mortality occurred in 18% (4/22), 25% (9/36) and 44% (4/9), respectively. Conclusion DDTB presents early as febrile illness after SOT, and carries a high mortality risk. Donors should be screened, with particular attention to risk factors. Table 1: Summary of Characteristics of Donors and Recipients With DDTB Characteristics N (% or range) Age, year 48 (23–68) Gender, M (N = 35) 21 (60) Type of transplant Kidney 13 (36.1) Liver 6 (16.7) Lung/heart–lung 16 (44.4) Heart 1 (2.8) h/o T-cell depleting agent (N = 9) 5 (55.6) h/o acute rejection (N = 19) 11 (57.9) Immunosuppressive regimen w/Cyclosporine (N = 21) 8 (38.1) Donor characteristics, N = 28 Deceased 24 (85.7) Living 2 (7.1) Not specified 2 (7.1) Donor risk factor for TBa Latent or active TB 5 Residence in endemic country 13 Socio-economicb 5 None 5 Type of TB Pulmonary 13 (36.1) Extrapulmonary 10 (27.8) Disseminated 13 (36.1) Type of DDTB Proven 17 Probable 8 Possible 11 Clinical presentation (N = 33) Fever 20 (60.6) Otherc 13 (39.4) Time to diagnosis, med in months 2.7 (0.2–29) Diagnosis, N = 34a AFB smear or culture 30 Histopathology 8 PCR 2 Outcome Graft loss or failure (N = 22) 4 (18) Death 9 (25) amay have more than one. bHomelessness, incarceration, alcohol abuse, and travel. cPain (2), cough/dyspnea (3), Effusion (1), nephritis (1), nausea (1) no symptoms (5), NR,–not reported. Disclosures All authors: No reported disclosures.

Background Donor-derived toxoplasmosis (DDT) is a severe and potentially life-threatening infection after solid-organ transplantation (SOT). Serologic testing for Toxoplasma gondii is required for all deceased donors per OPTN policy as of 4/6/17. To assess the impact of universal donor testing and the optimal approach to DDT prevention, we analyzed potential DDT cases reviewed by DTAC. Methods All potential Toxoplasma donor-derived transmission events adjudicated by DTAC from 2008 to 2018 were reviewed. A standardized classification algorithm was used to adjudicate each event as proven, probable, possible, unlikely, excluded or intervention without disease transmission. Results Twenty-eight potential DDT events were reported between 2008 and 2018. Proven or probable (p/p) DDT developed in 16 organ recipients from 15 donors. In the 9 years prior to the new testing requirement (January 2008–March 2017) 11 organ recipients from 10 donors had p/p DDT (0.13 transmissions per 1,000 donors); in the first 21 months of the new testing requirement 5 recipients from 5 donors had p/p DDT (0.27 transmissions per 1,000 donors), rate ratio 2.15; 95% CI 0.577, 6.90;P = 0.18. 10.2% of 18,328 donors tested between April 6, 2017 and December 31, 2018 were Toxoplasma IgG seropositive. Recipient pre-SOT serostatus was unknown in 4 of 5 and negative in 1 case of p/p DDT. Trimethoprim/sulfamethoxazole prophylaxis was either stopped at < 3 months or not used in all 5 cases. Infection was diagnosed a median of 103 days (range 42–153) post-transplant. Four of the 5 recipients died. Conclusion DDT remains a morbid infection in both heart and non-heart recipients. Despite an apparent increase in DDT reporting to DTAC, it is unlikely that the actual incidence of this donor-derived event is increasing. Rather, with universal serologic screening of deceased donors and wider access to molecular diagnostics, DDT is increasingly recognized and diagnosed. To decrease risk for illness and death related to DDT, broader pre-transplant recipient serologic testing and use of prophylaxis or monitoring for high-risk serostatus recipients (Toxoplasma D+/R−) is critical. The optimal duration of prophylaxis is uncertain at this time and warrants further study. Disclosures All authors: No reported disclosures.

Background Cryptococcosis is an important fungal complication of solid organ transplantation (SOT); cases occurring within 6 months posttransplant are often severe and sometimes donor derived. Morbidity can be related to delayed recognition of clinical symptoms or lack of communications among the SOT recipient centers. To better understand transmission of Cryptococcus (Crypto) and to identify opportunities for improved identification and communication, all potential donor-derived transmission events (PDDTE) of Crypto reported to OPTN/UNOS ad hoc Disease Transmission Advisory Committee (DTAC) over 10 years were analyzed. Methods All Crypto cases reported to DTAC between January 2008 and December 2017 were reviewed retrospectively as potential donor-derived transmission events (PDDTE). Likelihood of donor-derivation was adjudicated based on recipient and donor data. Results Fourty-six cases of Crypto were reported to DTAC during this period, involving 145 SOT recipients. Of the Proven or Probable donor-derived Crypto cases (n = 9), transmission occurred in 15 recipients; 2 donors each transmitted Crypto to 3 different recipients. Of the Possible cases, 9 recipients were affected. Six recipients with PDDTE Crypto died. Eight recipients received antifungal medications that would prevent transmission of Crypto (classified as intervention without disease transmission). UNOS Region 7 had the highest number donors with 10, with 6 and 7 from Regions 2 and 3, respectively. No cases C. gattii were reported; however, most of the reports to DTAC did not discriminate between C. neoformans and C. gattii. Conclusion This DTAC case series highlights both donor and recipient-derived cryptococcal infections and their potential to have devastating clinical impact. These data also highlight important delays in recognizing Crypto in SOT and in communicating these results to other centers when a PDDTE is possible. Transplant teams should have a high level of suspicion for Crypto in SOT, particularly in those with fever of unknown etiology, pulmonary infiltrates, headaches, and mental status changes. In the future, it may be helpful for transplant center to perform specific testing to discriminate between Cryptococcus species to understand their differential impact in SOT. Disclosures D. F. Florescu, Astellas: Grant Investigator, Grant recipient. C. R. Wolfe, Merck: Scientific Advisor, Consulting fee.

We present a case of donor-derived coccidioidomycosis in a cardiac transplant patient and review previous cases of donor-derived coccidioidomycosis in solid organ transplant. Donor-derived coccidioidomycosis is rare, can be difficult to diagnose and has significant mortality., Background. Endocarditis is a rare manifestation of infection with Coccidioides. This is the first reported case of donor-derived Coccidioides endocarditis obtained from a heart transplant. Methods. We present a unique case of donor-derived Coccidioides immitis endocarditis and disseminated infection in a heart transplant patient. We also conducted a review of the literature to identify other cases of donor-derived coccidioidomycosis in solid organ transplant recipients and reviewed their clinical characteristics. Results. Fifteen prior cases of donor-derived coccidioidomycosis were identified. A majority of these cases were diagnosed by positive culture (83%). Mortality was high at 58%. Conclusions. Clinicians should maintain a high index of suspicion for disseminated coccidioidomycosis in patients who received transplants with organs from donors with a history of residing in endemic regions.