A woman in Michigan died after contracting COVID-19 from a double-lung transplant she received from a donor who showed no signs or symptoms of the virus.

Officials at the University of Michigan Medical School say it may be the first proven transmission of COVID-19 via an organ transplant in the U.S. "We would absolutely not have used the lungs if we'd had a positive COVID test," said Dr. Daniel Kaul, director of Michigan Medicine's transplant infectious disease service, who co-authored a report about the case, in a statement.

The transplant took place in fall 2020 at University Hospital in Ann Arbor, where a woman with chronic obstructive lung disease received the lungs of a Midwestern woman who died from severe brain injury in a car accident. Samples from the donor’s nose and throat prior to the procedure came back negative for SARS-CoV-2.

The recipient experienced a fever, a drop in blood pressure and labored breathing three days later, and eventually developed septic shock and heart function problems. Imaging confirmed an infection and a molecular swab test was used to assess the nose and throat samples, which were taken 48 hours after her lungs were procured, and still showed no signs of the virus. The donor also had no history of recent travel, COVID-19 symptoms or exposure to infected people.

Doctors then assessed a sample of fluid washed from deep within the lungs, which tested positive. In addition, the surgeon who performed the transplant tested positive four days later, with genetic screening confirming that the virus came from the donor.

While the surgeon eventually recovered, the transplant recipient developed multisystem organ failure and despite receiving the approved drug treatment, remdesivir, and convalescent blood plasma, ended up on extracorporeal membrane oxygenation. Life support was eventually withdrawn and she died 61 days after the transplant.

Though not required by the Organ Procurement and Transplantation Network, organ donors have been tested routinely during the pandemic, and the case is the only confirmed one among nearly 40,000 transplants in 2020. While believed to be an isolated incident, it illustrates the need for sampling from donors’ low respiratory tracts, in addition to their noses and throats, prior to transplants, says Kaul, especially in areas with high rates of COVID-19.

Obtaining and testing such samples can be difficult, however, to do so in a timely manner, and risks introducing infection into the donated lungs. In addition, viral transmissions from organ donors to recipients remain rare, occurring in fewer than 1% of transplant recipients, and the medical risks for patients who reject an organ transplant are much higher, according to Dr. David Klassen, chief medical officer with the United Network for Organ Sharing, the federal contractor that runs the OPTN.

"The risks of turning down transplants are catastrophic," he said. "I don't think patients should be afraid of the transplant process."

It was not clear if the virus could be transmitted via solid organ transplants before the incident, though other incidents have been suspected. Because no other organs were transplanted, the incident does not provide insight on testing protocols for other organs, and it is not known if the virus can be transmitted from other donor organs such as the heart, kidney and liver.

The report on the case was published in the American Journal of Transplantation.

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