title: Investigation of a possible iatrogenic case of Creutzfeldt-Jakob disease after a neurosurgical procedure.
abstract: OBJECTIVE
  To investigate a case of Creutzfeldt-Jakob disease (CJD) possibly acquired from contaminated neurosurgical instruments.
  
  
  METHODS
  Retrospective review of medical records, hospital databases, service log books, and state vital statistics.
  
  
  METHODS
  A tertiary care hospital (hospital A) in Missouri.
  
  
  METHODS
  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.
authors.affiliation: Division of Viral and Rickettsial Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.
authors.forename: Natalie
authors.initials: N
authors.lastname: Keeler
authors.forename: Lawrence B
authors.initials: LB
authors.lastname: Schonberger
authors.forename: Ermias D
authors.initials: ED
authors.lastname: Belay
authors.forename: Lynne
authors.initials: L
authors.lastname: Sehulster
authors.forename: George
authors.initials: G
authors.lastname: Turabelidze
authors.forename: James J
authors.initials: JJ
authors.lastname: Sejvar
mesh_terms: D000328:Adult; D007562:Creutzfeldt-Jakob Syndrome / Q000175:diagnosis / Q000635:transmission*; D005260:Female; D006801:Humans; D007049:Iatrogenic Disease; D019635:Neurosurgical Procedures / Q000009:adverse effects*; D012189:Retrospective Studies