Doctors initially attributed the donor's death to other causes. But during an investigation prompted by the kidney recipient's death in February, lab testing found evidence of rabies in the donor's brain tissue and also detected encephalitis, a brain inflammation that can be caused by rabies.
The virus was consistent with raccoon rabies and was nearly identical to a virus found in the transplanted kidney and other tissue from the recipient, an Army veteran from Maryland, said the report, compiled by researchers from the federal Centers for Disease Control and Prevention and others and published Tuesday in the Journal of the American Medical Association.
Investigators don't know if organs given to three other patients - the North Carolina donor's heart, liver and second kidney-were infected with the rabies virus, but all three were considered at risk. Their recipients received anti-rabies treatment "and to date remain well," said CDC researcher Dr. Neil Vora, the lead author.
While the case is rare, it underscores the need to improve screening for would-be organ donors with suspected encephalitis, the report's authors say. They say a uniform donor questionnaire could help better identify risk factors for the virus and that rabies should be considered in donors with unexplained encephalitis.
The United Network for Organ Sharing issued guidance last year to help organ procurement organizations screen for encephalitis and other central nervous system infections in potential donors. It urged caution in accepting organs from donors with an untreated central nervous system infection.
The researchers want to improve awareness that rabies can be the cause of encephalitis, said co-author Dr. Sridhar Basavaraju, another CDC researcher. But he added, "We wouldn't want to mandate any screening that would potentially exclude transplantable organs."
The study is based on a review of laboratory tests and medical records, and interviews with relatives of the organ donor and recipient. It provides the most detailed account of the chain of events that led to the two deaths and the investigation that followed, which prompted health authorities to recommend vaccines for dozens of people who were in contact with the donor or recipients.
The case attracted public attention because of the rare circumstances, including the long time between infection and death of the transplant recipient - about a year and a half.
It was just the third documented transmission of rabies through a solid organ transplant, the report says.
Also, there are only roughly two human rabies deaths in the United States each year, and all but two domestic cases between 2000 and 2010 were linked to bats, according to the report. The authors say raccoons pose an under-recognized risk for infection and their spread into urban areas raises concern.
The patient who received the North Carolina donor's kidney at the Walter Reed National Military Medical Center in Bethesda, Md. in September 2011 has not been publicly identified.
The donor was 20-year-old William Edward Small, an avid outdoorsman from North Carolina who got sick after a fishing trip in Florida, where he was undergoing Air Force training.
Small's initial symptoms included nausea, vomiting and fever - which could indicate rabies but also other less serious conditions that are much more common. Doctors thought Small had eaten tainted fish.
Questioned during the organ procurement process, relatives said they didn't know of any recent risk of rabies exposure, and doctors did not test him.
Investigators say they learned during subsequent interviews that Small trapped raccoons for use as bait during hunting-dog training exercises, and had been bitten at least twice by the animals, 18 months and seven months before developing symptoms. He was not treated for those bites.
"If you don't ask specific questions, you don't get specific answers," said Dr. Michael Green, chairman of an advisory committee on disease transmission for the United Network for Organ Sharing.
"At the time these questions are being asked initially, families are often traumatized, in shock," Green said. "They're losing a loved one. They may not be thinking normally or straight or remember all those details."
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A study of older men found those who regularly skipped breakfast had a 27 percent higher risk of a heart attack than those who ate a morning meal. There's no reason why the results wouldn't apply to other people, too, the Harvard researchers said.
Other studies have suggested a link between breakfast and obesity, high blood pressure, diabetes and other health problems seen as precursors to heart problems.
"But no studies looked at long-term risk of heart attack," said Eric Rimm, one of the study authors at the Harvard School of Public Health.
Why would skipping breakfast be a heart attack risk?
Experts aren't certain, but here's what they think: People who don't eat breakfast are more likely to be hungrier later in the day and eat larger meals. Those meals mean the body must process a larger amount of calories in a shorter amount of time. That can spike sugar levels in the blood and perhaps lead to clogged arteries.
But is a stack of syrupy pancakes, greasy eggs and lots of bacon really better than eating nothing?
The researchers did not ask what the study participants ate for breakfast, and were not prepared to pass judgment on whether a fatty, sugary breakfast is better than no breakfast at all.
Other experts agreed that it's hard to say.
"We don't know whether it's the timing or content of breakfast that's important. It's probably both," said Andrew Odegaard, a University of Minnesota researcher who has studied a link between skipping breakfast and health problems like obesity and high blood pressure.
"Generally, people who eat breakfast tend to eat a healthier diet," he added.
The new research was released Monday by the journal Circulation. It was an observational study, so it's not designed to prove a cause and effect. But when done well, such studies can reveal important health risks.
The researchers surveyed nearly 27,000 men about their eating habits in 1992. About 13 percent of them said they regularly skipped breakfast. They all were educated health professionals - like dentists and veterinarians - and were at least 45.
Over the next 16 years, 1,527 suffered fatal or non-fatal heart attacks, including 171 who had said they regularly skipped breakfast.
In other words, over 7 percent of the men who skipped breakfast had heart attacks, compared to nearly 6 percent of those who ate breakfast.
The researchers calculated the increased risk at 27 percent, taking into account other factors like smoking, drinking, diet and health problems like high blood pressure and obesity.
As many as 18 percent of U.S. adults regularly skip breakfast, according to federal estimates. So the study could be important news for many, Rimm said.
"It's a really simple message," he said. "Breakfast is an important meal."
ST. LOUIS (AP) - Shelby Miller threw six shutout innings and Allen Craig drove in a pair of runs to lead the St. Louis Cardinals to a 4-1 win over the Philadelphia Phillies on Tuesday night.
Miller (10-6) broke out of a three-start slump with one of his finest efforts of the season. He had given up 10 earned runs in 12 2-3 innings over his previous three starts. He was working on 12 days rest and gave up three hits while striking out six and walking one. He is the third St. Louis starter to reach double-digits in wins joining Adam Wainwright (13-5) and Lance Lynn (11-5).
The Cardinals have won four of five and 10 of 13. Philadelphia lost its third straight game.
Edward Mujica picked up his 29th save in 31 opportunities. Randy Choate, Seth Maness and Trevor Rosenthal followed Miller to mound.