Record number:
376
Adverse Occurrence type:
MPHO Type:
Time to detection:
20 days
Alerting signals, symptoms, evidence of occurrence:
31 year old female developed right leg twitching, neck spasm, numbness, headache, nausea, seeing flashing lights 20 days after kidney transplantation. Two days later she developed seizures. On day 26 a brain biopsy showed ameba infection Balamuthia mandrillaris and she died on day 75.
Demonstration of imputability or root cause:
Certain. Recipient and donor were infected by B. mandrillaris. Donor was a young boy who had a transient febrile illness diagnosed as infulenza type A. A week later he had a sudden headache and seizures. Seizures were recurrent , leading to a subarachnoid hemorrhage, brain swelling herniation and death 15 days after his onset of headache. He was diagnosed ADEM but autopsy showed brain ameba infection. Two kidneys, liver and heart were donated. Heart and liver recipients received preemptive treatment and did not get infected.
Imputability grade:
3 Definite/Certain/Proven
Keywords:
References:
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