Background: Donor-derived Strongyloides stercoralis infection is an emerging public health concern among solid-organ transplant recipients. Immunosuppressed transplant recipients are at risk for hyperinfection syndrome and disseminated infection. Recipients may have either reactivation of chronic infection or donor-derived infection with Strongyloides. Donor-derived infection is believed to be less common than reactivation, but the true incidence is not known and is likely to be more common than previously suggested.

Methods: We compiled data from seven clusters of donor-derived strongyloidiasis investigated by the CDC from 2009 to 2012. A definitive cluster of donor-derived infection was defined as positive Strongyloides serology in the donor, with negative pre-transplant serology in the recipient(s). A possible cluster was defined as one with recipient(s) without a history of Strongyloides infection prior to organ transplantation, but with clinical disease or positive serology post-transplant in the absence of confirmed infection in the donor.

Results: Four of the seven investigations occurred in 2012. Twenty case-patients received solid-organ transplants from seven donors. Three donors resided in Pennsylvania (43%; n=3/7). Six of seven donors were foreign-born in Strongyloides endemic areas; the seventh was a homeless man residing in the southeastern US. None had documentation of donor screening for Strongyloides infection prior to organ procurement. The majority of organs transplanted were kidneys (70%; n=14/20), followed by livers (25%; n=5/20). Over half of the recipients (n=12) presented with symptoms consistent with strongyloidiasis, including four with hyperinfection or disseminated disease. Two of the 20 patients expired from pulmonary complications; in neither case was Strongyloides infection definitively linked to the cause of death. In six of the seven investigations Strongyloides infection was confirmed as definitively donor-derived in the infected recipients; the seventh investigation was classified as a possible donor-derived cluster.

Conclusion: Donor-derived strongyloidiasis is a serious public health concern highlighted by the recent increase of recognized cases. As severe infection in immunocompromised hosts may be fatal, risk assessment of donors from endemic areas should be determined at the time of organ procurement to allow for early treatment of recipients.

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