Three deaths after knee surgery prompt CDC search for similar cases

Nov 21, 2001 (CIDRAP News)—A cluster of three unexplained deaths after routine knee surgeries in Minnesota has prompted the Centers for Disease Control and Prevention (CDC) to hunt for similar cases nationwide and caused Minnesota health officials to call a 1-week moratorium on elective knee surgeries. But state health officials reported this afternoon that an "exhaustive" investigation has revealed no link between the cases, and they advised hospitals to resume scheduling elective knee surgeries Monday, Nov 26.

A 23-year-old man and a 78-year-old man both died Nov 11, 4 days and 2 days, respectively, after having surgery at St. Cloud (Minn.) Hospital, according to a Nov 18 news release from the Minnesota Department of Health (MDH). In addition, a 60-year-old man died Nov 16 after having surgery Nov 13 at Douglas County Hospital in Alexandria, Minn., the MHD reported. The victims have been identified as Brian Lykins, 23; Wayne Hulterstrum, 78; and Ronald Bettin, 60.

The CDC published a brief notice in this week's Morbidity and Mortality Weekly Report describing the cases and inviting readers to report similar cases. Further, a CDC telephone press conference today was devoted to the mysterious cases instead of to the expected topic, anthrax.

Tests of Lykins' blood indicated an infection with Clostridium sordellii, a rare infection, according to MDH. No evidence of C sordellii has been found in specimens from the other patients, but their clinical course was very similar to that of Lykins, according to the MMWR report.

In all three patients, "Symptoms included severe abdominal pain and a sudden decline in blood pressure followed by a fulminant course with death within 24 hours of symptom onset," the report says. "The clinical course was consistent with septic or cardiogenic shock. After 5 days of incubation, a blood culture taken from one of the patients yielded Clostridium sordellii."

The MDH's Nov 18 news release said all Minnesota hospitals and surgery centers were asked to suspend elective knee operations for a week while the three cases are being investigated. In another release this afternoon, officials said they had found no link between the three cases and no other deaths similar to those cases. No C sordellii organisms were found in the other two patients, MDH reported. "Unless new information comes to our attention between now and Sunday, we now believe it's safe to start offering this procedure again," said Harry Hull, MD, Minnesota state epidemiologist.

The three knee surgeries were done by separate teams in three different operating rooms, state officials said. Investigators have been examining the products and drugs used in the three surgeries and have found no common thread, the MDH said. Further, "After receiving reports of several hundred possible post-surgical deaths and illlnesses since Sunday—and intensively investigating as many as six of them—MDH was able to find no cases that were clearly similar to the three deaths that prompted the moratorium," the release stated.

However, the state investigation is continuing, MDH press office spokesman Buddy Ferguson said today. "The reason we're letting the moratorium ride out till Sunday is that if something does turn up, things could change," he said.

The MMWR report says the CDC is seeking reports of cases elsewhere that involved orthopedic surgery conducted since Oct 1. Specifically, the agency wants to know about patients who had surgery on the knee or another large joint and, within 7 days afterward, had "hypotension and other clinical findings of cardiogenic or septic shock or abdominal pain" with no other known cause, and who required intensive care or died.

At today's press conference, CDC officials did not call for a wider moratorium on knee or other orthopedic procedures. When questioned about the Minnesota moratorium, medical epidemiologist Dan Jernigan said, "We certainly think that with the available information they had they made the best judgment they could, and we are supporting them in the investigation right now."

In discussing the reasons for the CDC's concern about the cases, Jernigan said further, "The possibility arises that when you have a patient in two separate hospitals, there may be a product or device that's associated with it. We need to identify it quickly if there is anything . . . that could be affecting a lot of people." But he also said, "The likelihood that we'll find some specific cause is low, unless something really jumps out."

Jernigan said C sordellii can be cultured from the intestines, but infections in humans are very rare. When a reporter noted that the three patients were all farmers and asked if that could be a factor, Jernigan said, "This has not been risk factor in past investigations of this type of infection."

See also:

MDH press release, "Health department advises hospitals that they can resume knee surgeries on Monday"
http://www.health.state.mn.us/news/pressrel/surgery.html

CDC: Unexplained deaths following knee surgery—Minnesota, November 2001. MMWR 2001(Nov 23):50:46;1035-6
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5046a3.htm

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