A scratch, a kidney transplant, and two deaths: The rare Rabies chain that left US CDC and doctors stunned

It started with a kitten. In late October 2024, a man from rural Idaho was outside on his property when a skunk approached him while he was holding a small cat. During the encounter, which left the skunk unconscious, the donor sustained a scratch on his shin that bled. He didn't think much of it. He almost certainly didn't think he'd been bitten. He attributed the skunk's behaviour to predatory aggression toward the kitten.That scratch would eventually kill him. And then, through one of the most baffling transmission chains in recent medical history, it would kill someone else entirely.The CDC has since described what happened as a "likely three-step transmission chain" from a bat to a skunk, to the organ donor, and finally to a kidney transplant recipient in Michigan. Two men, in two different states, connected only by a surgical procedure, both died from a disease that most people associate with feral animals.In the five weeks following the skunk encounter, the Idaho man began experiencing hallucinations, trouble swallowing, difficulty walking, and a stiff neck. His family watched him deteriorate rapidly. Then, two days after those symptoms emerged, he was found unresponsive at home, suspected of cardiac arrest. He was resuscitated and hospitalized but never regained consciousness. He was declared brain dead and removed from life support on hospital day five. Nobody suspected rabies and that detail never made it into the Donor Risk Assessment Interview questionnaire. The family's account of what happened that October evening only emerged later, during the investigation, when it was already too late. His organs were recovered. The left kidney, heart, lungs, and both corneas were prepared for donation. In December 2024, his kidney went to a Michigan man being treated at the University of Toledo Medical Center in Ohio. About five weeks after the transplant, the Michigan recipient began experiencing tremors, lower extremity weakness, confusion, and urinary incontinence. His family insisted he'd had no contact with animals. He later developed fever, difficulty swallowing, and a fear of drinking water, a characteristic symptom of rabies. He later required ventilation and died one week after symptoms began. That was 51 days after he received the transplant. Testing showed both men had the same bat-linked strain of rabies, meaning the virus was almost certainly transmitted through the transplant itself. Specifically, CDC detected rabies virus RNA consistent with a silver-haired bat rabies virus variant in a biopsy sample of the right kidney. The silver-haired bat variant, a strain that circulates in North American wildlife, picked up by the skunk, passed to the donor through that shin scratch, and then transplanted into another human being's body in an Ohio operating room. The Idaho donor's organs didn't only go to Michigan. Four ocular grafts were prepared from recovered corneas. Three patients, one each from California, Idaho, and New Mexico, received grafts in December 2024 and January 2025. A fourth planned transplant, to a patient in Missouri, was cancelled once the investigation was underway.While investigation of the donor's rabies status was ongoing, the cornea recipients underwent precautionary graft removal and received post-exposure prophylaxis (PEP). They remained asymptomatic. That's the best possible outcome from an otherwise grim situation — quick action, preventive treatment, and three people who didn't end up like the kidney recipient. Health officials reached out to 370 people who could have been in contact with the donor or the infected tissue. Forty-six of them were recommended to receive PEP. Meanwhile the donor’s heart and lungs were not transplanted. “The heart and lungs of the donor were not transplanted but were used in training procedures at a Maryland medical research facility. By the time of the public health investigation, no specimens were available for testing,” the CDC says.Rabies transmission through donated organs is extremely rare. Since 1978, four organ donors have spread rabies to 13 recipients. Of those 13 people, six survived after treatment, while seven died. This was the fourth transplant-transmitted rabies event in the United States since 1978.