Adverse Occurrence type:
Alerting signals, symptoms, evidence of occurrence:
Donor: Misdiagnosed cocaine overdose but started with dramatic hydrophobia. Had bat bite. Cocaine user recently in jail for drugs. RECIPIENTS: rapid mental status change, seizures, respiratory failure, encephalitis,. KIDNEY RECIP A (CB): On posttransplant day 27, kidney recipient A (CB) was hospitalized with abdominal, side and back pain. On day 28 she was agitated and restless, on day 29 had a tonic seizure followed by weakness, confusion and verbal inappropriateness. On day 30 she had a petit mal- type seizure progressing into a grand mal seizure with frothing of the mouth. On day 31 she developed respiratory failure, was intubated and became agitated. By day 32 she was obtunded and flaccid. On day 35 she developed cerebral edema and mild herniation on head CT that was not present earlier in the day. She died on day 36. She had been hypothermic for 7 days (93-96.3F.) and had episodes of bradycardia to 40s. KIDNEY RECIP B (JH): On postop day ,he graduated from high school, after receiving diploma, he vomited LIVER RECIP:ILIAC ARTERY RECIP:.Artery used to aid implanting liver from a different donor.,
Demonstration of imputability or root cause:
Certain. Uncommon disease in donor and 4 recipients (liver, kidneys, iliac artery). donor and recipient antibodies.
Update: investigation of rabies infections in organ donor and transplant recipients--Alabama, Arkansas, Oklahoma, and Texas, 2004.
Rabies encephalomyelitis: clinical, neuroradiological, and pathological findings in 4 transplant recipients.