Category: learning curve

Come for the unusual medical case study, stay for the line about the skunk.

Yeah – this is a very unfortunate case of human to human transmission of rabies via a kidney transplant, resulting in the death of the recipient. (The donor was obviously already dead, but more on that later…)

When I used to work in a lab that tested donor specimens for transplants, we never tested for rabies virus. But that’s because there isn’t any rabies virus in the UK, where we were doing the testing. So it would have all been negative anyway.

In the US, there are around 5000 rabies cases in animals each year, but fewer than 3 in humans. Quite literally a one in a million thing. So you might excuse them for not testing for it either. But this does seem to be a bit of an unusual case in a few ways.

Firstly, that the donor died in unusual circumstances. Cause of death at the time was listed as cardiac arrest. But that came after some interesting symptoms:

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.

And there was mention of a scratch from a skunk in the Donor Risk Assessment Interview:

The DRAI is a tool to document a potential donor’s health history, given to their next-of-kin, and is a series of questions.

But it seems that it was overlooked. At this point, given that history (and the power of hindsight), I’m already wondering why they thought that he was a suitable candidate for organ donation. But hey, I’m not a doctor and I’m not in America. Who knows what rules apply there?

Only after the death of the recipient were the family of the donor interviewed again, where the skunk line came out:

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 behaviour to predatory aggression toward the kitten.

Emphasis by me. Skunk battery by the guy in Idaho.
The battle was clearly won that day, but as we now know, the war was lost.

But, skunk scratch or not, unusual symptoms prior to alleged cardiac arrest or not, the organ donation went ahead. (And to be fair, post-incident testing on other specimens taken at the time of the operation didn’t yield any positive results for rabies.)

Sadly for the recipient, 5 weeks after the transplant, things went downhill very rapidly. Within two weeks of his first symptoms and just 5 days after rabies became suspected, he died.

But the kidney was not the only organ that was donated:

The heart and lungs went to a medical training facility in Maryland. Concerningly:

By the time of the public health investigation, no specimens were available for testing.

And 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. 

And ominously:

CDC detected rabies virus RNA consistent with a silver-haired bat rabies virus variant in one previously implanted corneal graft.

We are not told which one. I wonder if the recipients were? They were all treated.

So now, everyone who had been in contact with donor, recipient or organs had to be identified, counselled and potentially tested and/or treated. That was 380 individuals.
I know that all that boring paperwork is tedious and irritating, but these sort of situations are exactly why we do it.

No other persons or animals were exposed to the presumed rabid skunk.

And there probably wasn’t any documentation if there was any exposure anyway. Skunks are notoriously poor at following even the most basic recordkeeping SOPs.

Finally, what will be done to stop this from happening again?

CDC, the Health Resources and Services Administration, and partners are reviewing the occurrence of reported exposures to animals among donors to identify interventions to further reduce transplant-associated rabies risk.

No standard guidance currently exists for addressing reported donor animal exposures by transplant teams.

If a potential donor, particularly one with acute encephalopathy, had a bite or scratch from a rabies-susceptible animal during the preceding year, transplant teams should consider consulting public health officials to determine rabies risk.

Much like the rest of the world, there is a real shortage of transplant organs in the USA. But that doesn’t mean that seemingly simple red flags should be overlooked. It won’t knock many potential transplants out given the rarity of rabies cases over there, but it will prevent any further scenarios like this.