Finding into death of Gurpal Sandhu

64y · Female·Lymphocytic choriomeningitis virus (LCMV)-like arenavirus infection, post liver transplant

A 64-year-old woman died on 3 January 2007 from a lymphocytic choriomeningitis virus (LCMV)-like arenavirus acquired through cadaveric liver transplantation. The donor had recently returned from Serbia with unexplained weight loss, lethargy, and headaches. Two other recipients of the same donor's organs also died from the same novel virus within 6 days. Post-hoc investigations identified this previously unknown arenavirus. The screening process at the time was reasonable and could not have prevented these deaths, as the virus was unknown and undetectable. Key clinical lessons include: improved inter-hospital communication about multi-recipient donor outcomes is essential to recognise clustering of symptoms sooner; donor-coordinated liaison should be systematized post-transplant; and families require regular, clear communication about deteriorating patients to reduce distress and anger. Early recognition of the common neurological deterioration might have prompted sooner investigation but would not have altered the fatal outcomes.