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Adverse Occurrence type:
Time to detection:
Alerting signals, symptoms, evidence of occurrence:
In January 1985, a 58 year old man who had a clavicle fracture, received a transplanted lyophilized bone chip from a donor who was a drug misuser, and who had died from drug overdosage. The patient developed AIDS.
Demonstration of imputability or root cause:
The donor was not tested for HIV—at the time there were only around 150 cases of AIDS in Germany. At least two more patients, out of 12 who received bone transplants from the same donor, later died from AIDS.
Karcher, H. L. (1997). "HIV transmitted by bone graft." BMJ 314(7090): 1300.