Transmission of Yellow Fever Vaccine Virus Through Blood Transfusion and Organ Transplantation in the USA in 2021: Report of an Investigation

BACKGROUND: In 2021, four patients who had received solid organ transplants in the USA developed encephalitis beginning 2-6 weeks after transplantation from a common organ donor. We describe an investigation into the cause of encephalitis in these patients. METHODS: From Nov 7, 2021, to Feb 24, 2022, we conducted a public health investigation involving 15 agencies and medical centres in the USA. We tested various specimens (blood, cerebrospinal fluid, intraocular fluid, serum, and tissues) from the organ donor and recipients by serology, RT-PCR, immunohistochemistry, metagenomic next-generation sequencing, and host gene expression, and conducted a traceback of blood transfusions received by the organ donor. FINDINGS: We identified one read from yellow fever virus in cerebrospinal fluid from the recipient of a kidney using metagenomic next-generation sequencing. Recent infection with yellow fever virus was confirmed in all four organ recipients by identification of yellow fever virus RNA consistent with the 17D vaccine strain in brain tissue from one recipient and seroconversion after transplantation in three recipients. Two patients recovered and two patients had no neurological recovery and died. 3 days before organ procurement, the organ donor received a blood transfusion from a donor who had received a yellow fever vaccine 6 days before blood donation. INTERPRETATION: This investigation substantiates the use of metagenomic next-generation sequencing for the broad-based detection of rare or unexpected pathogens. Health-care workers providing vaccinations should inform patients of the need to defer blood donation for at least 2 weeks after receiving a yellow fever vaccine. Despite mitigation strategies and safety interventions, a low risk of transfusion-transmitted infections remains. FUNDING: US Centers for Disease Control and Prevention (CDC), the Biomedical Advanced Research and Development Authority, and the CDC Epidemiology and Laboratory Capacity Cooperative Agreement for Infectious Diseases

A case of infectious crystalline keratopathy after corneal cross-linking

Purpose: To present a case of infectious crystalline keratopathy after corneal cross-linking in a child with delayed wound healing, and its successful management with antibiotic and anti-fungal eye drops. Observations: A 14-year-old male presented for a second opinion with a non-staining crystalline keratopathy after corneal crosslinking for progressive keratoconus. He reportedly rubbed his eyes vigorously in the post-operative course and had a slowly healing epithelial defect. He was treated with several antibiotic drops and was put on high dose topical difluprednate drops post-procedure for persistent corneal haze. His infection continued to progress until steroids were stopped and he was treated with topical voriconazole. While cultures were negative, the patient's visual acuity and corneal lesions improved significantly after starting voriconazole therapy and stopping steroid drops, pointing to a diagnosis of infectious crystalline keratopathy. Conclusions and Importance: This is one of the first case reports to describe a primary infectious crystalline keratopathy after a corneal cross-linking procedure, and the first to describe this phenomenon in a child with delayed corneal re-epithelialization. Though corneal cross-linking is a relatively safe procedure, atypical infections like crystalline keratopathy can occur in these patients in the setting of topical steroid use. Atypical organisms such as fungi should always be on the differential, especially for patients with recalcitrant infection in the setting of immunosuppression

Pediatric corneal transplants

Purpose of reviewPediatric keratoplasty poses unique challenges in clinical and surgical management. However, successful transplantation can afford a child vision in an otherwise poorly seeing eye. This review will provide an update on recent advances in pediatric keratoplasty.Recent findingsAlthough children who receive corneal transplants remain at increased risk of rejection, infection, and graft dehiscence compared with adult corneal transplant recipients, new surgical techniques, and advances in clinical management have led to better outcomes. Surgical modifications in penetrating keratoplasty (PKP) offer increased stabilization of the delicate pediatric eye. Lamellar surgery, including endothelial keratoplasty and deep anterior lamellar keratoplasty, can target specific diseased tissue in children with potentially fewer complications. The keratoprosthesis can be used successfully in children when the chance of success with PKP is especially low.SummaryAs our knowledge of prognostic indicators and surgical techniques continues to grow, we can offer children safer and more targeted surgeries for some of the most challenging corneal diseases. Ultimately, successful transplantation with long-term graft survival can be obtained by a multidisciplinary approach, with care across ophthalmic specialties, and a commitment to long-term follow-up by the patient's family.Columbia Univ, Med Ctr, Dept Ophthalmol, New York, NY 10027 USAUniv Fed São Paulo, UNIFESP, Dept Ophthalmol & Visual Sci, Paulista Sch Med, São Paulo, SP, BrazilWills Eye Hosp & Res Inst, Cornea Serv, Philadelphia, PA USAJohns Hopkins Univ, Wilmer Eye Inst, Baltimore, MD USAUniv Fed São Paulo, UNIFESP, Dept Ophthalmol & Visual Sci, Paulista Sch Med, São Paulo, SP, BrazilWeb of Scienc

Diabetes distress in adults with type 1 diabetes: Prevalence, incidence and change over time

AIMS: To document the prevalence and 9-month incidence of elevated diabetes distress (DD) and the stability of DD over time using both single threshold and minimal clinically important differences (MCID) approaches. METHODS: Adults with type 1 diabetes (T1D) (N=224) completed the 28-item T1-Diabetes Distress Scale (T1-DDS) at baseline and 9 months. A T1-DDS threshold was identified with spline analysis and MCID was calculated from the standard error of measurement. RESULTS: Analyses supported a cut-point of ≥2.0 for elevated DD. The prevalence and 9-month incidence of elevated DD was 42.1% and 54.4%, respectively. MCID was +/−0.19 but varied by subscale (.26 to .50). Elevated DD was stable: only 20% crossed 2.0 over 9 months. MCID analyses showed that change also occurred among those who remained either below or above 2.0 over time. Change varied by source of distress, with Powerlessness the most prevalent and stable. Using MCID, only participant age, gender and number of complications predicted change. CONCLUSIONS: The prevalence, 9-month incidence and stability of elevated DD is high among adults with T1D, with change based on source of DD. We propose a combined cut-point/MCID framework for measuring change in DD, since each approach reflects unique characteristics of change over time