Clostridium perfringens

Record number: 
Adverse Occurrence type: 
MPHO Type: 
Estimated frequency: 
Both of the donor's corneas caused C perf infection
Time to detection: 
12 hours
Alerting signals, symptoms, evidence of occurrence: 
Two cornea recipients developed severe endophthalmitis within 24 hours of transplantation of corneas contaminated with C. perfringens. Case 1: Severe pain, nausea and vomiting developed in a 64 yr old male within 12 hours of surgery along with increased intraocular pressure and decreased light perception. Culture of intraocular fluid grew C. perfringens. Both surgeries took place on same day at same facility. The donor had died of disseminated colon cancer, body refrigerated 3 hr after death, eyes recovered 8 hr after death, stored in gentamicin and streptomycin and used within 48 hours of storage. Cultures of the cornea prior to surgery and of each patient's intraocular fluid after developing signs of infection grew Clostridium perfringens.
Demonstration of imputability or root cause: 
Level 4. Certain. The same organism was found on the donor cornea before surgery and in the patient's infected eye.
Imputability grade: 
3 Definite/Certain/Proven
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