A third instance of rabies transmission following organ transplantation has occurred, with a patient dying 18 months after receiving a kidney from a deceased donor who was not known to be infected with the rabies virus, researchers reported.

The extended incubation period was an unusual clinical feature because in the two previous episodes of transmission, all unvaccinated recipients developed symptoms within 6 weeks and died, according to Matthew Kuehnert, MD, of the CDC in Atlanta, and colleagues.

Also distinctive was the fact that three other individuals who received organs from the same donor remained asymptomatic and only developed rabies antibodies after post-exposure prophylaxis, the investigators wrote in the July 24/31 Journal of the American Medical Association.

Those previous cases had suggested "a high infectivity rate and an incubation period of approximately 6 weeks in unvaccinated immunosuppressed recipients of solid organs from donors with rabies," according to the investigators.

However, in the present case, that pattern wasn't followed. The organ donor was an apparently healthy male who had returned from a fishing trip and developed symptoms of nausea, vomiting, and paresthesias, and then seizures, altered mental status, dysphagia for liquids, and hemodynamic instability.

The presumed diagnosis at the time of death was ciguatera -- a marine toxin found in certain reef fish -- poisoning.

Family members reported no known exposure to rabies, and examination of the cerebrospinal fluid found no evidence of infectious disease.

Subsequent investigations determined that ciguatera poisoning was "extremely unlikely," because of the water temperature, and the final diagnosis was severe gastroenteritis.

The recipient initially was diagnosed with sciatica when seen for hip pain radiating to the leg, but was subsequently hospitalized with symptoms including fever, diaphoresis, and abdominal pain in the region of the transplanted kidney.

Encephalopathy followed, along with hemodynamic instability, and death occurred 3 weeks after admission.

Serologic tests conducted shortly before he died found IgG and IgM antibodies to rabies virus as well as neutralizing antibodies to the virus in serum.

His family members indicated that he had no exposures to infected animals, so local authorities and the CDC conducted an investigation of the kidney transplant as a possible source of the infection.

It turned out that the donor had a history of exposure to wildlife, including trapping raccoons in North Carolina, and had been bitten twice by the animals, which were not available for rabies testing.

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