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Adverse Occurrence type:
100% Transmission ocurred in both liver and kidney recipients
Time to detection:
Alerting signals, symptoms, evidence of occurrence:
DONOR: 11-month-old male from a high tuberculosis (TB) incidence country. Cause of death: Dandy Walker syndrome with cerebral infarction. TB was not suspected during the donation process and autopsy was not performed. Chest X ray normal. RECIPIENTS: LIVER: a 4-year-old recipient without history or background of TB developed liver TB (Mycobacterium tuberculosis isolated in gastric fluid), gender not stated. TST not performed, received TB treatment, alive. KIDNEY: a double kidney transplant in a 49 year-old TST negative recipient developed positive PPD skin test. The recipient was treated with isoniazid for 9 months, alive.
Demonstration of imputability or root cause:
The two infected recipients together with the fact that the donor’s parents belonged to the Romanian community (community with high incidence of TB) are consistent with a donor-transmitted TB (probable transmission according to Disease Transmission Advisory Committee criteria).
Coll E, Torre-Cisneros J, Calvo R, Garrido G, Matesanz R. Incidence of tuberculosis in deceased-organ donors and transmission risk to recipients in Spain. Transplantation. 2013 Jul 27;96(2):205-10.