key: cord-0780860-f0gsyner
authors: Nelson, Susan; Curran, Christopher C.; Sutcliffe, David L; Rofaiel, George; Chang, Yeh-Chung; Easterling, Larry; Wood, R. Patrick
title: nnSARS-CoV-2 Antibody Serology Testing in a 3-month-old Organ Donor, A Case Report and Review of Available Literature
date: 2021-07-02
journal: Transplant Proc
DOI: 10.1016/j.transproceed.2021.06.028
sha: 863bfb3af156009e38826b907806999af165ea35
doc_id: 780860
cord_uid: f0gsyner

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has become a highly prevalent infectious disease. Currently, organs are not being transplanted from SARS-CoV-2 positive donors. It remains unclear as to how to differentiate active from recovered patients. We report our recent experience of a 3-month-old deceased organ donor who died as the result of an anoxic brain injury following a cardiopulmonary arrest (presumed SIDS). The child was born to a mother presumed to have the Coronavirus Disease 2019 (COVID-19). The donor tested negative for SARS-CoV-2 RT-PCR and positive for SARS-CoV-2 IgA antibodies. We suspect this is the first known report of its kind and noteworthy for the organ donation and transplantation community.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has become a highly prevalent infectious disease. Currently, organs are not being transplanted from SARS-CoV-2 positive donors. It remains unclear as to how to differentiate active from recovered patients. We report our recent experience of a 3-month-old deceased organ donor who died as the result of an anoxic brain injury following a cardiopulmonary arrest (presumed SIDS). The child was born to a mother presumed to have the Coronavirus Disease 2019 (COVID-19). The donor tested negative for SARS-CoV-2 RT-PCR and positive for SARS-CoV-2 IgA antibodies. We suspect this is the first known report of its kind and noteworthy for the organ donation and transplantation community.

We report the circumstances of a 3-month old, 5.1kg African American male deceased organ donor in Texas. The child was born in early February 2020 and died in May of 2020. The donor was admitted following a cardiorespiratory arrest, initially presumed to be SIDS. On the morning of admission, the donor experienced an unknown duration of downtime and approximately one hour of CPR until return of circulation. The donor's adoptive mother reported the child had been well the previous evening with the exception of emesis 30 minutes after an evening feeding. On the morning of admission SARS-CoV-2 RT-PCR testing was performed on nasopharyngeal and oropharyngeal swabs which resulted as negative.

However, the sample was positive for human rhinovirus. The chest x-ray from the day of admission demonstrated patchy airspace disease in bilateral upper lobes. A CT scan of the abdomen and pelvis included visualization of the lower lobes of the lungs and the radiologist appreciated bilateral lower lobe atelectasis, left greater than right. The donor progressed to brain death and was declared brain dead by clinical exam including apnea exam, and EEG, on hospital day 3. Authorization for organ and tissue donation was obtained from the donor's adoptive mother following brain death declaration.

Presenting Concern and Clinical Findings:

The donor medical history was notable only for prematurity of 36-weeks' gestation requiring a one-month neonatal intensive care unit (NICU) admission without identifiable sequela. On the day of birth, the donor's birth mother was admitted to the hospital complaining of respiratory distress and was considered a person under investigation (PUI) for COVID-19, but confirmatory SARS-CoV-2 testing was not performed due to a lack of available testing at that time. The donor had been adopted at birth and had remained in the care of the adoptive mother following NICU discharge. The adoptive mother provided the medical and social history interview at time of organ donation. The interview also revealed that the donor's birth mother had a history of homelessness and illicit drug use, including during pregnancy. The donor did not receive breastmilk from the birth mother, nor any other source, at any time. No other medical or social information was available for the donor's birth mother or biological father and neither could be contacted to obtain further information; for this reason, the donor was categorized as PHS Increased Risk. During a subsequent interview, the donor's adoptive mother reported that while the donor was in her care, she was fostering 2 other children; a 1-year old and a 3-year old who were siblings.

During the month of March, when the donor was 1-month old, the 1-year old had diarrhea and a fever while the 3-year old had vomiting, cough, and a fever. Both children were treated for ear infections and responded well. The adoptive mother reports that she felt tired and congested during this same time period, but this was thought to be related to her own immunosuppressive disorder as well as caring for three young children. None of the members of the household were under investigation or tested for SARS-CoV-2.

Standard donor serology and NAT testing was performed with CMV total antibody and EBV IgG antibody positivity. SARS-CoV-2 RT-PCR testing, having been performed on hospital day 1, was not repeated. Given that the donor's birth mother had been reported to be a PUI for COVID-19 at the time of Discussion:

In this case report, the absence of SARS-CoV-2 virus was determined through a negative RT-PCR, and negative IgG and IgM antibodies. However, IgA antibodies were detected, resulting in the decline of organs by some transplant programs. Other programs were more confident and ultimately accepted these organs, resulting in transplantation of the donor's heart and kidneys.

As with all areas of healthcare, the COVID-19 pandemic has had significant impact on organ donation and transplantation. Deceased donor testing for SARS-CoV-2 has enabled organs to be safely transplanted due to transplant centers being reassured of minimal risk to infectious spread of the virus.

As the number of people reportedly infected with SARS-CoV-2 has increased to over 30 million in the IgA antibodies are produced as a response to infection and can be found as a first line of defense in mucosal secretions and as a second line of defense in serum (2) . As it pertains to SARS-CoV-2, IgA acts as an immune barrier and can neutralize the virus before it binds to the epithelial cells (3).

IgG antibodies can be transferred across the placenta to fetus to provide protection to the infant but IgM and IgA are thought to not be able to cross the placenta (4) . In this case presented, the donor did indeed have evidence serum IgA specific to SARS-CoV-2, likely representing infectious exposure that led to an immune response, as opposed to passive spread of protective antibody. It is likely that this particular donor had a primary exposure and cleared the virus. Moreover, the updated clinical history in the corresponding recipients demonstrates that the use of organs from a pediatric donor with evidence of previous SARS-CoV-2 infection may be safe for transplant.

Organ recovery from deceased donors with prior COVID-19: A case series

IgA function -variations on a theme

The role of IgA in COVID-19

Efficacy of the placental barrier for immunoglobulins: correlations between maternal, paternal and fetal immunoglobulin levels

Antibodies in Infants Born to Mothers With COVID-19 Pneumonia