Record number:
21
Adverse Occurrence type:
MPHO Type:
Estimated frequency:
Only 4 cases observed despite many cases using bone from same type of donor in past year.
Time to detection:
2 weeks - 6 months
Alerting signals, symptoms, evidence of occurrence:
Four cases of tuberculosis (TB) transmitted by use of frozen rib allografts in scoliosis surgery. Ribs obtained from patients with active tuberculosis (TB) during thoracoplasty. Ribs stored frozen in penicillin and streptomycin. Case 1: 2 weeks-wound dehiscence, 4 months: fever, pleurisy, tuberculous lymphadenopathy, disseminated tuberculosis (TB); Case 2: "weeks" later wound sinus drainage. 4 months: caseous tuberculosis (TB) wound infection;
Case 3: chronic wound drainage since surgery, at 10 weeks enlarged nodes and wound grew tuberculosis (TB); Case 4: at 3 months, chronic wound drainage with sinus. At 6 months, tuberculosis (TB) found in non-healed wound, bone non-union. No systemic symptoms.
Demonstration of imputability or root cause:
Certain. Ribs removed at thoracoplasty for pulmonary tuberculosis and stored in bone banks. Recipients developed localised TB, demonstrated by positive smear, culture and histology of axillary lymphonode and caseous material.
Imputability grade:
3 Definite/Certain/Proven
References:
Suggest references:
AAA