*Purpose: Donor derived West Nile Virus(WNV) Infections can occur but rare. We are presenting four cases that were seen at our transplant center

*Methods: Case 1: 55 male, ESRD secondary to Ig A Nephropathy, received a donation after cardiac death kidney transplant (DCDKTx). Patient had delayed graft function (DGF) and discharged with stable function on day+ 13. Readmitted with fever and weakness on day+15. CSF WNV Antibodies (Ab) were initially negative. Serum west Nile Ab (Ig G and Ig M) and Polymerese chain reaction (PCR) were positive. Patient became severely obtunded. Brain MRI on day+ 32 showed bilateral T2 hyperintensity of the thalami likely representing encephalitis. Patient alive with trach and PEG tube placement. Resumed cyclosporine-based IS. Case 2: 73 male, ESRD secondary to Diabetes and hypertension(HTN) had DCDKTx from the same donor. Postoperatively patient had DGF and discharged with stable GFR on day+ 7. Readmitted on day+ 27 with fever, altered mental status, chills and rapidly progressed to obtundation. Serum west Nile Antibodies (Ig G and Ig M) and PCR were positive. MRI brain showed negative for encephalitis. He got intubated, PEG tube, and became nonresponsive. Family opted for comfort care and patient expired. For case 1 and case 2, a possible donor-derived infection reported. The donor had negative WNV Nucleic acid amplification (NAT) assays at the time of offer, but had high unexplained fevers. retrospective serum testing by request was positive for WNV Ig M. Case 3:65 woman, ESRD secondary to diabetes and HTN had donation after brain death kidney transplant. Graft function were stable and discharged on day+ 5. She was re-admitted on day+ 54 with fever 100.7 f, altered mental status. MRI of brain negative. Within 3-4 days, she was severe encephalopathic, myoclonus and brain dead. Serum positive for WNV Ig G and Ig M. Case 4: 58 male, ESRD from Polycystic kidney disease had DCDKTx one year prior to presenting with fever 100.3. Serum and CSF positive for WNV Ig M and negative for Ig G. MRI of brain negative. Clinical status worsened quickly became nonverbal, profound weak. Discharged to Skilled Nursing facility (SNF) with trach and PEG tube. Case 3 and case 4 were having exposure to farm animals at their house. All 4 cases got Thymoglobulin Induction and maintained on calcineurin based immunosuppression. Surprisingly all 4 cases were seen in same month.

*Results: All received empiric antibiotics on admission, Intravenous Immunoglobulin (Ig) and Dexamethasone therapy after stopping Immunosuppression. One year post transplant patient (case 4) is over all better compared to fresh transplants

*Conclusions: Negative NAT assays for WNV in a deceased donor in the presence of unexplained high fevers is not sufficient to rule out WNV particularly in endemic regions. With a negative NAT, but clinical concern, antibody tests or PCR tests should be considered.

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