Record number:
587
Adverse Occurrence type:
MPHO Type:
Alerting signals, symptoms, evidence of occurrence:
The frozen unprocessed femoral head allograft donor was a 62 yr old man who became infected with HTLV-1 from a blood transfusion in 1987 during hip surgery. One month later he developed a fever, rash and transient radial nerve palsy with seroconversion. Four years later he donated a femoral head during a hip arthroplasty but was not tested for HTLV antibodies. The femoral head was used and the recipient seroconverted without symptoms of HTLV infection.
Demonstration of imputability or root cause:
Level 4. Certain, Proven. Donor had clinical HTLV infection and positive test. Years later donated an HTLV-infected femoral head that was used as a frozen unprocessed bone. After receipt of the HTLV-infected femoral head the recipient had an asymptomatic seroconversion.
Imputability grade:
3 Definite/Certain/Proven
Keywords:
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