Fatal TB outbreak shows importance of screening tissue transplants


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Today a new study published in Morbidity and Mortality Weekly Report describes an outbreak of tuberculosis (TB) linked to contaminated bone allografts (tissue transplant) from the same donor.

On July 7, 2023, a patient who had spinal fusion surgery that incorporated a bone allograft product containing live cells experienced symptoms of meningitis 5 weeks after surgery. Mycobacterium tuberculosis was identified in the cerebrospinal fluid of the patient, and state health authorities contacted the Centers for Disease Control and Prevention (CDC).

Clinicians were reminded of a 2021 TB outbreak, which involved 113 recipients in 18 states, related to bone allograf M tuberculosis transmission. Before 2021, bone allograft–related M tuberculosis transmission had last been reported in the United Kingdom in 1953.

On July 11, a different state health department contacted the CDC after a patient complained of a persistent surgical site infection after using the same bone allograft product during a back surgery. Drainage from the site showed M tuberculosis.

CDC recommended that any unused units be quarantined, recipients be evaluated and started on multidrug treatment for TB disease regardless of signs and symptoms.

Within hours of the July 11 case, the CDC contacted state health departments and quarantined the 53 units of tissue that had not yet been distributed and provided a list of all healthcare facilities that had purchased tissue units from that lot, alerting eight hospitals and five dental offices in seven states (California, Louisiana, Michigan, New York, Oregon, Texas, and Virginia), the authors said.

"CDC recommended that any unused units be quarantined, recipients be evaluated and started on multidrug treatment for TB disease regardless of signs and symptoms," the authors wrote. "And health care facilities implement TB-specific infection prevention and control measures during follow-up encounters with these patients."

Two initial patients died from TB

An investigation found 36 patients had undergone procedures using at least one unit from the product lot contaminated with M tuberculosis. By December 20, 2023, 5 of the 36 patients had lab-confirmed TB, and 10 others had clinical symptoms.

The two initial cases reported in July both died from TB infections.

The authors said the clinicians' quick action to notify the CDC prevented at least 53 subsequent transplants with the contaminated tissue. They also said the outbreak emphasizes the importance of screening donor tissue.

"This outbreak serves as another reminder that TB has not been eliminated from the United States, where up to 13 million persons of all ages are living with untreated and often undiagnosed latent TB infection (LTBI)," they concluded. "Informed consent, including discussion of infectious disease risks and alternative treatment options, is needed before patients receive tissue allografts, particularly those containing live cells, which carry a higher risk for disease transmission."

In the United States, roughly 58,000 donors provide tissue allografts for 2.5 million transplants annually.

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