Candida albicans

Record number:

Adverse Occurrence type:

MPHO Type:

Time to detection:

5 months

Alerting signals, symptoms, evidence of occurrence:

50 year old male had human aortic valve allograft for aortic insufficiency. Five months later he developed hemiparalysis, intracranial hemorrhage (mycotic emboli from infected allograft ), fungemia, candida albicans cervical spine osteomyelitis (at 7 months) developed due to mycotic emboli from infected heart valve. Infected valve was replaced with another heart valve allograft. He later died of recurrent infection.

Demonstration of imputability or root cause:

Disputed in court and settled out of court. Same organism was found on pericardium and tendon at tissue recovery and also in the processing room. One of two heart recipients infected. No DNA testing to prove yeast from donor tissue and patient infected valve were identical.

Imputability grade:

2 Probable

Keywords:

intracranial hemorrhage