Record number:
389
Adverse Occurrence type:
MPHO Type:
Estimated frequency:
Both donors transmitted T cruzi to each heart recipients but not to each of the 2 kidney recipients or each liver recipient. Two infected hearts but no transmissions to 4 kidney or 2 liver recipients: 100% transmission rate to heart recipients but 2 of 8 or 25% transmission rate overall to all organ recipients.
Time to detection:
6 - 7 weeks
Alerting signals, symptoms, evidence of occurrence:
Patient A: 64 year old male had atrial flutter, reduced kidney function, reduced ejection fraction of 35%–40% (with diffuse hypokinesis of the septum and inferomedial wall), for several weeks after heart transplantation. Anorexia, fever, and diarrhea developed six weeks after transplant. T cruzi was found in blood and heart biopsy. After nifurtimox therapy symptoms resolved and parasitemia cleared but he died of heart failure (no T cruzi in heart at autopsy) 20 weeks after transplantation. Patient B: A 73 year old male developed fever, fatigue, and abdominal rash 7 weeks after surgery. T cruzi found in blood and after nifurtimox threatment blood cleared of T cruzi but he died of heart failure 25 weeks after transplant.
Demonstration of imputability or root cause:
Proven: Both donors positive for T cruzi antibodies, Donor A: Had traveled to endemic area of Mexico and was seropositive for T. cruzi antibodies by RIPA and borderline-positive by IFA. Recipient A: peripheral blood smear revealed T. cruzi trypomastigotes, blood cultures were positive for T. cruzi, and endomyocardial biopsy specimens contained amastigotes. Donor B: born in El Salvador and recently moved to U.S. Positive for T. cruzi antibodies by RIPA. Recipient B: blood smear revealed T. cruzi trypomastigotes, blood cultures were positive for T. cruzi, PCR-positive for T. cruzi., and seronegative
Imputability grade:
3 Definite/Certain/Proven
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