Epidemiologic Notes and Reports Transmission of HIV Through Bone Transplantation: Case Report and Public Health Recommendations

In February 1988, a bone transplant recipient was diagnosed with acquired immunodeficiency syndrome (AIDS) after being found positive for antibody to human immunodeficiency virus (HIV) and developing Pneumocystis carinii pneumonia (PCP). The recipient had no known risk for HIV infection other than the bone grafting procedure, and the bone donor was subsequently found to have been infected with HIV. A summary of the investigation of the recipient and the donor follows.

Recipient. In November 1984, a woman with progressive idiopathic scoliosis underwent a fusion of a lateral curvature of her spine. She received no blood transfusions. Allograft bone obtained from the hospital bone bank was used in the procedure. The recipient was seen by a physician 21 days after surgery for complaints of fevers with temperatures to 102 F, night sweats, diarrhea, nausea with vomiting, and enlarged lymph nodes. On physical examination, the physician noted bilateral cervical and axillary lymphadenopathy. The patient's symptoms resolved over the next 3 days.

In July 1986, 20 months after receiving the bone allograft, the recipient was evaluated again when she complained of enlarged axillary lymph nodes that she had found during a breast self-examination. The physician noted "almond-sized" axillary and anterior cervical glands. No change in the size of these nodes was found on a second examination by another physician 6 months later, and no further diagnostic procedures were performed.

In February 1988, the patient returned to her physician with a 2-week history of malaise, fever, nonproductive cough, and generalized chest pain. On physical examination, the physician noted oral and vaginal candidiasis and generalized lymphadenopathy. She was tested and found positive for HIV antibody and was subsequently diagnosed with PCP and AIDS. The patient's illness improved with therapy that included pentamidine, azidothymidine, and ventilatory support; she has not developed other HIV-related illness.

On interview, the recipient denied the use of intravenous drugs or previous blood transfusions. She was employed as a health-care worker, and although she had washed gynecologic specula without using gloves, she had never had a needlestick injury or a mucous membrane exposure to blood or other body secretions in the course of her work. She had been married since 4 years before the transplantation and denied other sex partners. Her husband also denied extramarital sex partners and denied any other risk for HIV infection since 1979. He was tested for HIV antibody in February and April 1988; both tests were negative.

Donor. The bone donor was a 52-year-old man who had donated his left femoral head, which was excised during a hip arthroplasty procedure performed for degenerative joint disease in November 1984. At the time of tissue procurement, the donor said that he had had a "cyst" removed from the left side of his neck in July 1984. It was not recorded in the medical record whether the donor was asked about known risks associated with AIDS. On physical examination at the time of donation, a 2-cm node in the right cervical area was found. The donor's bone was harvested under sterile conditions and stored at -80 C, and no sterilizing procedures were performed. The bone was used in the recipient's surgery 24 days after procurement.

In July 1986, the donor developed PCP, was tested and found positive for HIV antibody, and was diagnosed as having AIDS. At that time, the donor reported previous intravenous-drug use and denied other risks for HIV infection. The donor's wife was also tested and found positive for HIV antibody. Subsequent review of the donor's medical record from another hospital revealed that a lymph node, not a cyst, was biopsied in July 1984. The pathology report noted nonspecific hyperplastic changes, and no further evaluation was performed. The donor died in April 1987 of recurrent PCP and atypical mycobacteriosis. Reported by: AIDS Program, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: This is the first reported case of HIV transmission by bone transplantation. Also, the recipient is the first person reported to CDC as having transplantation-associated AIDS. Previous reports have identified transmission of HIV through transplantation of kidney, liver, heart, pancreas (1-3), possibly by skin (4), and by artificial insemination (5), but none of these infected recipients have been reported as having developed AIDS.

Bone grafts may be procured from the recipient's own bone (autograft) or from either living donors who are having bone removed during surgical procedures or cadaveric donors (allograft) (6,7). The use of bone autografts will reduce the risk of HIV transmission by bone transplantation.

The Public Health Service has recommended that all donors of tissue and organ allografts be evaluated for risks associated with HIV infection and tested for HIV antibody (1,8,9). On August 10, 1988, representatives of the American Association of Tissue Banks (AATB), American Academy of Orthopedic Surgery, Food and Drug Administration, and CDC met to discuss draft recommendations for the prevention of HIV transmission by bone transplantation. Based on this meeting and previous recommendations, the Public Health Service also recommends the following measures to prevent HIV transmission*:

For donors of bone allografts, as well as other organ and tissue allografts, the assessment of risks for HIV infection should include reviewing the donor's medical record, testing the donor for HIV antibody, and interviewing living donors. The interview should consist of standardized questions that identify risks for HIV infection. The donor's responses to these questions should be recorded on a form signed by the donor acknowledging that the recorded responses are correct. The completed form should be kept in the tissue bank with other records for the donor.

As previously recommended by AATB, all living donors of bone should be retested at least 90 days after tissue procurement, and only bone from living donors negative for HIV antibody on this repeat testing should be distributed for transplantation (10). Bone from donors not available for retesting, including cadaveric donors, should be used when bone from retested living donors is not available or is not appropriate for use in the anticipated surgical procedure.

References

1. CDC. Human immunodeficiency virus infection transmitted from an organ donor screened for HIV antibody--North Carolina. MMWR 1987;36:306-8.

2. Neumayer H-H, Fassbinder W, Kresse S, Wagner K. Human T-lymphotropic virus III antibody screening in kidney transplant recipients and patients receiving maintenance hemodialysis. Transplant Proc 1987;XIX:2169-71.

3. Erice A, Rhame F, Sullivan C, Dunn D, Jackson B, Balfour HH Jr. Human immunodeficiency virus (HIV) infection in organ transplant recipients (OTRS). IV International Conference on AIDS. Book 2. Stockholm, June 12-16,1988:363.

4. Clarke JA. HIV transmission and skin grafts (Letter). Lancet 1987;1:983.

5. Stewart GJ, Tyler JPP, Cunningham AL, Barr JA, Driscoll GL, Gold J. Transmission of human T-cell lymphotropic virus type III (HTLV-III) by artificial insemination by donor. Lancet 1985;2:581-4.

6. Goldberg VM, Stevenson S. Natural history of autografts and allografts. Clin Orthop 1987; 225:7-16.

7. Mankin HJ, Doppelt S, Tomford W. Clinical experience with allograft implantation: the first ten years. Clin Orthop 1983;174:69-86.

8. CDC. Testing donors of organs, tissues, and semen for antibody to human T-lymphotropic virus type III/lymphadenopathy-associated virus. MMWR 1985;34:294.

9. CDC. Semen banking, organ and tissue transplantation, and HIV antibody testing. MMWR 1988;37:57-8,63.

10. American Association of Tissue Banks. Standards for surgical bone banking. Arlington, Virginia: American Association of Tissue Banks, 1987. (Revision to standards, effective January 15, 1988, section C1.330). *These Public Health Service recommendations may not reflect the views of all individual consultants or the organizations they represented.

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