Creutzfeldt-Jacob disease (CJD)

Record number:

405

Adverse Occurrence type:

CJD

MPHO Type:

Dura mater

Estimated frequency:

Time to detection:

16 months

Alerting signals, symptoms, evidence of occurrence:

Spain case 1: in 1985, a 19-year-old man developed gait ataxia, blurred vision, dysarthria, and dysmetria 16 months after surgery for cerebellar astrocytoma using dura mater (LYODURA). Two weeks later he became progressively demented, developed myoclonic jerks, and died 21 months after onset. A right frontal cerebral biopsy showed spongiform changes consistent with CJD. The patient was one of over a hundred others dying of CJD acquired from contaminated dura (LYODURA) made by pooled processing by Braun, Germany

Demonstration of imputability or root cause:

Level 4. Certain. Although no clinical information was known about the donor, the patient was one of over a hundred others worldwide dying of CJD acquired from contaminated freeze-dried dura mater allograft , LYODURA brand, made by pooled processing involving dura from many inadequately screened donors by B. Braun Melsungen AG, Germany

Imputability grade:

3 Definite/Certain/Proven

Keywords:

CJD (Creutzfeldt-Jacob disease)

cornea transplantation

spongiform encephalopathy