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Investigation of a Possible Iatrogenic Case of Creutzfeldt-Jakob Disease After a Neurosurgical Procedure

Published online by Cambridge University Press:  21 June 2016

Natalie Keeler ,
Lawrence B. Schonberger ,
Ermias D. Belay ,
Lynne Sehulster ,
George Turabelidze  and
James J. Sejvar
Natalie Keeler
Affiliation:
Divisions of Viral and Rickettsial Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
Lawrence B. Schonberger
Affiliation:
Divisions of Viral and Rickettsial Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
Ermias D. Belay
Affiliation:
Divisions of Viral and Rickettsial Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
Lynne Sehulster
Affiliation:
Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
George Turabelidze
Affiliation:
Missouri Department of Health and Senior Services, St. Louis
James J. Sejvar*
Affiliation:
Divisions of Viral and Rickettsial Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
*
Division of Viral and Rickettsial Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop-A-39, Atlanta, GA30333 (zea3@cdc.gov)
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Abstract

Objective.

To investigate a case of Creutzfeldt-Jakob disease (CJD) possibly acquired from contaminated neurosurgical instruments.

Design.

Retrospective review of medical records, hospital databases, service log books, and state vital statistics.

Setting.

A tertiary care hospital (hospital A) in Missouri.

Patients.

The case patient was a 38-year-old African American woman with a 9-month history of progressive memory loss, visual disturbances, and dementia. She underwent neurosurgery in November 1996. CJD was confirmed in April 2004 by immunodiagnostic testing of brain biopsy samples. All patients who underwent neurosurgery at the same hospital within 6 months before or after the case patient's procedure were identified and investigated for preoperative or postoperative evidence of CJD.

Results.

We reviewed data on 268 neurosurgical procedures, 84 pathology log entries, and 60 death certificates for neurosurgical patients at hospital A and identified 2 suspected cases of CJD. Clinical features and definitive prion testing of stored brain biopsy samples excluded a diagnosis of CJD. Standard operating room procedures were in place, but specific protocols for handling instruments potentially contaminated with prions were not used.

Conclusions.

Neurosurgical instruments were not implicated as the source exposure for CJD in the case patient. The 2 patients with suspected CJD were identified from different data sources, suggesting good internal consistency in data collection. The key elements of this investigation are suggested for use in future investigations into potential cases of iatrogenic CJD.

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 27 , Issue 12 , December 2006 , pp. 1352 - 1357
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2006

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