Record number:
373
Adverse Occurrence type:
MPHO Type:
Estimated frequency:
3 of 3 recipients developed A fumigatus infection
Time to detection:
6 months
Alerting signals, symptoms, evidence of occurrence:
Asymptomatic heart recipient, until 6 months postop when he developed intraocular A. fumigatus infection (blurred vision, diplopia). A transesophageal echocardiography (TEE) showed aortic valve (AV) vegetations and urgent AV replacement showed A. fumigatus in vegetations and intramyocardial abscess. All three recipients recovered.
Demonstration of imputability or root cause:
Level 4. Certain. Proven donor transmission of A fumigatus since all recipients (2 kidney recipients, one heart recipient) developed A fumigatus infection. Same fungus isolated from donor and recipient.
Imputability grade:
3 Definite/Certain/Proven
Keywords:
Suggest references:
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