Adverse Occurrence type:
Time to detection:
Alerting signals, symptoms, evidence of occurrence:
In June 2003, a 59-year-old Canadian woman had slight memory loss, decreased level of consciousness, myoclonus, focal seizures, decreased ability to speak and nystagmus. She received a Tutoplast Dura mater graft in 1992 (11 years earlier) during a surgery for excision of a benign brain tumour. She died one month later. Autopsy confirmed classical CJD. No donor information reported.
Demonstration of imputability or root cause:
Level 2. Possible. The dura, Tutoplast brand, used in this case had been implicated in transmitting CJD in another reported case. Although donor data is not reported, the recipient of the dura died of CJD confirmed by autopsy.