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UPMC: 2 patients might have died in mold outbreak at Presbyterian

Ben Schmitt
| Thursday, Sept. 17, 2015, 11:51 a.m.
The main entrance of UPMC Presbyterian in Oakland.
Trib Total Media
The main entrance of UPMC Presbyterian in Oakland.

Toilets in UPMC Presbyterian's cardiothoracic intensive care unit have emerged as a potential source of fungal infections that may have contributed to the deaths of two patients and sickened a third.

Two heart transplant patients contracted mold infections and subsequently died over the past year in the now-shuttered 20-bed unit, UPMC's Chief Quality Officer Tami Minnier said Thursday.

A third patient, who had a lung transplant, remains hospitalized in Presby with a mold infection and other ailments.

“This is really an evolving investigation,” Minnier told the Tribune-Review. “I want to be right up front. I don't have all the answers yet. We are working as quickly and as effectively as we can.”

She said the two deaths cannot directly be attributed to mold because both patients were acutely ill at the time. She did not identify the patients but said their families have been notified, adding the prognosis of the third patient is “poor.”

The toilets in question are “modular,” meaning they are contained in a cabinet-like structure with a door. Splashing water could have soaked into the structure and led to mold, Minnier said.

She said the toilets are used in some ICUs because they give patients close access to a bathroom.

“This is not a firm answer,” she said of the toilet theory. “But they may be a source.”

The mold incidents date back to October 2014, when doctors discovered a fungal infection on the left leg of a heart transplant patient. In June, doctors discovered a different form of mold on the buttocks of another heart transplant patient, Minnier said, noting the mold can be seen by the naked eye.

“You can see like anything else when mold grows,” she said. “It's also growing long before you can see it, and that was the hard part about this whole situation. There was nothing visible in the room. If you walk into this ICU, you would think it's spotless, think it's clean.”

The hospitalized patient, who is male, contracted a fungal infection on his lung tissue. After his diagnosis, a physician recalled the previous mold cases in June and October, she said.

“We had one of our ICU physicians ... actually say, ‘Hmmm, I think I remember two previous cases in the last year,' ” Minnier said.

The explanation confused hospital safety expert Lawrence Muscarella.

“Dots were connected by a physician whose memory recalled previous mold infections?” asked Muscarella, a Philadelphia-based biomedical engineer who specializes in infection control. “It's unclear why the hospital apparently did not have an active surveillance system in place, as I recommend, that would have automatically alerted the staff that this was the third related fungal infection in the past year.”

Minnier described UPMC's infection surveillance protocols as “excellent” and “very active.”

Presby administrators closed the cardiothoracic ICU indefinitely and relocated its patients on Sept. 8, five days after doctors diagnosed the lung transplant patient with a mold infection. The Tribune-Review first reported the ICU's shutdown.

As part of their investigation, workers opened a wall in the patient's room where they found mold. A definitive source has not been established, although mold was later found in other portions of the unit, including the toilets.

Minnier said all three infected patients had been treated in the same ICU room. In total, 56 patients stayed in the room in question over the previous year, she said, adding that UPMC is unaware of any other infections.

Of those 56, eight — including the three infected — had organ transplants. Minnier identified the types of mold detected as rhizomucorm, lichtheimia and rhizopus.

The proper environment could cause several types of mold to thrive in the same area, said Dr. Amesh Adalja, a Pittsburgh-based infectious disease expert who serves as a spokesman for the Infectious Diseases Society of America. He said the molds in the UPMC cases are all similar and can prey on people with compromised immune systems.

“The outcome is usually not good with these types of infections,” he said. “If you have an environment conducive for one mold, you're going to have an environment conducive for other molds.”

The mold is sometimes found on rotten fruits and vegetables, Minnier explained, further complicating the search for a root cause.

“I can't say for sure that some of these families didn't bring it in,” she said. “I don't want to point any fingers, but it's possible.”

Pittsburgh attorney Anthony D'Amico, whose Downtown law firm, Savinis, D'Amico, & Kane, handles medical malpractice cases, said any potential legal action could turn on knowledge of the hospital staff and doctors. He has not been retained by anyone in the matter.

“The cause of action would be grounded in negligence; one would have to prove that someone knew or should have known about a medical threat to patients,” D'Amico said. “For example, if there's water dripping behind a ceiling tile and you know that, you might not see mold behind there, but you could know that it's likely going to grow over time.”

Mold has not been located in any other portion of the hospital, which is UPMC's flagship and the largest in Western Pennsylvania.

“It's just heartbreaking,” Minnier said. “I can't tell you how many hours we have already spent trying to understand it. I still feel like I am navigating a very active investigation.”

She said the general public and hospital staff should not fear infection.

“Unless you are severely immunocompromised, you are completely safe,” she said.

Ben Schmitt is a Trib Total Media staff writer. Reach him at (412) 320-7991 or bschmitt@tribweb.com.

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