NEW YORK (NYTIMES) - A woman in Michigan died 61 days after she received a pair of lungs from an organ donor who had been infected with the coronavirus, according to a case report published this month.
There was no indication that the donor, a woman fatally injured in a car accident, had Covid-19.
A radiograph of her chest had seemed clear, and a nasal-swab test for the coronavirus had returned a negative result.
But the doctors who worked with the lung recipient at University Hospital in Ann Arbor, Michigan, last fall began to question those results when their patient's condition worsened.
They concluded that the donor did indeed have Covid-19 - and that her lungs had infected not only the transplant patient, but also the surgeon.
It was the first confirmed case of a patient contracting the virus from the patient's organ donor, according to the authors of the peer-reviewed report, which was published in The American Journal of Transplantation on Feb 10.
"We want the transplant community to be aware that this can happen, and also that there may be things we can do to improve our success in screening patients for Covid," said the surgeon, Dr Jules Lin, an author of the report and the surgical director of the lung transplant programme at Michigan Medicine, the health system of the University of Michigan.
The report said that medical professionals should consider testing lung donors for the coronavirus using a sample from their lower respiratory tract, which extends into the lungs - beyond the reach of a nasal swab.
That kind of testing, which is invasive and not recommended for the general public, is not always available; currently, only about one-third of donated lungs are tested this way.
Dr David Klassen, the chief medical officer at the United Network for Organ Sharing, a nonprofit organisation that manages the nation's organ transplant system, said the case in Michigan was "very significant" despite its rarity.
"We want to minimise any chances of this reoccurring," he said.
Every organ donor in the United States is tested for the coronavirus in some way, Klassen said. The tests are not conducted by transplant surgeons; instead, they are typically overseen by nonprofit groups known as organ procurement organisations, which operate across the United States.
The Association of Organ Procurement Organisations referred questions to Gift of Life Michigan, which was not involved in this case. Its chief clinical officer, Bruce Nicely, said that many laboratories had refused to run samples from the lower lungs early in the pandemic, fearing that the procedure could contribute to the spread of the coronavirus.
"In response to the recommendations of the study, we are all for recommendations that improve safety and reduce the risk of infection," Nicely said, adding that his organisation has found a laboratory partner that is able to conduct testing of the lower respiratory tract.
When organs become available, time is of the essence. Some health facilities don't have the resources to test donors' lower respiratory tracts quickly for Covid-19.
Given those constraints, there is no requirement that lung donors be tested this way.
"We could mandate it," Klassen said. "But that might have the downstream effect of severely limiting the lungs that could be used for transplantation."
Of the nearly 40,000 organ transplants performed in the United States last year, the operation in Michigan was the only confirmed instance of a recipient contracting the coronavirus from a donor.
"It's important to emphasise that this is, fortunately, a rare event," said Dr Daniel R. Kaul, an author of the study and an infectious disease specialist at Michigan Medicine. The case, he said, should not dissuade people from getting transplants that could save their lives.
He added that the organ recipient, who had suffered from chronic obstructive lung disease, appeared to have had a successful operation until her condition worsened a few days later.
"All of a sudden, she had fever, low blood pressure, pneumonia," Kaul said. "I wasn't sure what was going on."
When further testing showed that the woman had Covid-19, the doctors looked to the lung donor. Her nasal-swab test had come back negative before the transplant, but those tests do not catch everything. The doctors needed to find a way to test the donor again.
As it turned out, they had exactly what they needed: a specimen from the deceased woman's lower respiratory tract. Michigan Medicine regularly collects such samples from lung donors to test them - not for Covid-19, but for ureaplasma, bacteria that can cause a rare syndrome.
The doctors found that they still had enough of the donor's sample to test for the coronavirus. The result showed that the donor had indeed been infected with the virus, and gene-sequence analysis showed that the patient had contracted the virus from the donor's lungs.
So had Lin, who had been wearing a surgical mask during the transplant operation. (The report he co-wrote recommends that transplant centres consider the benefits of wearing N95 masks throughout the hourslong procedure, even if the donor has tested negative for the coronavirus.)
He spent a couple of weeks recovering from the infection at home, he said, adding that the infection had not spread to his colleagues or his family members.
The patient, vulnerable in the wake of a major operation, did not recover despite doctors' attempts to save her with a series of treatments including convalescent plasma, steroids and remdesivir.
The doctors now hope that her case report will persuade more medical professionals to strengthen their coronavirus testing standards for organ donors, despite the logistical difficulties.
"I think these are barriers that we have to work to overcome," Lin said, "for the safety of our patients."