Littleton – A suburban Denver hospital said today that six patients may have been exposed to surgical instruments potentially tainted by a rare brain disease that killed another patient earlier this year – the second such case in Colorado in the past five years.
Littleton Adventist Hospital president and CEO David Crane went public after doctors consulted the six patients. He said the chance of any of them contracting the disease was “as remote as getting struck by lightning five times in a single day,” but it could take years for symptoms to show up and the only way to confirm infection is after death.
The disease is classic Creutzfeldt-Jakob, a fatal malady that strikes about one in a million people worldwide each year. It is different from variant Creutzfeldt-Jakob, which has been tied to meat contaminated with bovine spongiform encephalopathy, or mad cow disease.
The patient died March 23, six weeks after having brain surgery at Littleton Adventist and about a week after doctors first suspected the disease, hospital officials said. The patient, who was not identified, suffered an undisclosed traumatic injury Feb.13.
The patient deteriorated after surgery, officials said. After a month, doctors began to suspect CJD and the surgical instruments used on the patientwere quarantined.
During the month between the original operation and March 14, however, six other patients underwent neurosurgery and could have been exposed to the same instruments.
Subsequent tests at Case Western Reserve University confirmed CJD on May 9.
Dr. Lawrence Wood, the hospital’s chief medical officer, described instrument sterilization at Littleton Adventist as “state of the art,” but there is a slim chance the damaged protein that leads to the disease could endure standard sterilization techniques.
No Creutzfeldt-Jakob cases have been transmitted through surgical instruments since the 1970s, when sterilization guidelines were more lax, according to the federal Centers for Disease Control and Prevention. The last known case happened in Europe.
The CDC and Colorado health officials were consulted after the hospital learned of the diagnosis and neither agency required the hospital to contact the six surviving patients or alert the public.
State epidemiologist John Pape said there was so little chance of public danger that the matter was left to the hospital.
If the six patients have the disease, it could take years to manifest itself and a brain biopsy is the only way to confirm it, Wood said.
Crane said there has been no immediate reaction from the six patients and he said he had heard no threats of litigation.
“They’re still processing this news,” he said.
The case is similar to one in Colorado in 2001. Two people died of classic CJD at Exempla St. Joseph Hospital. Hospital officials said at least six other patients may have been exposed to the disease through surgical instruments or biopsies At Littleton Adventist, Wood said procedures are in place that include disposing of surgical instruments, but only in cases where CJD was suspected.
He said he is convinced the measures were adequate, but the hospital will now screen patients for potential symptoms such as dementia. It will also start tracking specific instruments that come in contact with every neurosurgery patient.
Wood said the patient had previously shown signs of dementia, but no one suspected a degenerative brain ailment like Creutzfeldt-Jakob was the killer. The patient did not contract CJD at the hospital, officials said.
“Littleton Adventist Hospital is a safe place,” Crane said.
