This story has been updated to reflect clarifications made today by the CDC regarding how many patients got fungal infections from breathing in mold spores.
Two of the four UPMC transplant patients who contracted fungal infections over the last year got their infections from breathing in mold spores, not from something rubbing against their skin, a federal health official said Thursday.
One of the other patients contracted an infection via skin, while the fourth contracted it from a “disseminated” source, meaning it came into the body from an outside point and spread throughout the body but the origin is not known.
Those are some of the findings from 16 days of ground-work at UPMC Presbyterian and Montefiore hospitals that ended Wednesday when the team of investigators from the federal Centers for Disease Control and Prevention concluded their on-site review of the mold infection “cluster.”
Three of the hospitals’ patients later died.
Two of those patients’ infections may have first appeared as a “skin manifestation,” Mary Brandt, the CDC’s chief of the mycotic disease branch, said Thursday.
But when the CDC’s team of investigators “looked at the [two patients’] charts, they decided it started from a pulmonary source. This started out as a pneumonia and then entered the blood stream.”
The CDC would not say which of the four patients contracted which type of infection, but an in-hospital autopsy released by the family of the first patient to die — Tracy Fischer, 47, a heart transplant patient from Erie who died in October, 2014 — said that she died from a disseminated infection.
UPMC has also said that the third patient to be infected — Che DuVall, 70, of Perryopolis, a double-lung transplant patient who is still battling his infection — contracted that infection through the open wound after transplant.
The other two patients, then, who potentially breathed in their fungal infections were possibly a still-unidentified heart transplant patient who died in June, and a liver transplant patient who died last month.
UPMC has said a definitive source has not been found for the mold that infected the patients between October, 2014 and this September, and CDC officials on Thursday would not discuss the final results of their investigation, which is ongoing. A final report could take a month or more to complete.
But the finding early in their work that two of the infections began by breathing in spores led the investigation team, aided by local and state health department employees, to spend less time looking into whether the hospital linens were the source of the mold, an early suspect in the cases.
“This just makes the point that we try not to jump to conclusions in these investigations,” Dr. Brandt said.
Problems with the hospital linen washing, collection or distribution processes have in past fungal investigations been found to be the source of fungal outbreaks, including a case 15 years ago at what was then Mercy Hospital in Pittsburgh.
But in the UPMC case they are probably “a little less likely” than other possible sources of the “cluster” found at UPMC, said Michael Bell, the CDC’s deputy director of the Division of Healthcare Quality Promotion.
On Sept. 14 that UPMC said it had shut down its cardiothoracic intensive care unit at Presbyterian on Sept. 3 because three transplant patients (the two heart and one lung patient) had contracted fungal infections. Three days later, Sept. 17, UPMC revealed the fourth patient, this time a liver transplant patient at Montefiore, had also become infected.
On Sept. 21, UPMC announced it was voluntarily shutting down its adult organ transplant program. It reopened six days later, but UPMC said one of the changes it was making as a precaution was ensuring that hospital linens stayed wrapped in plastic until they are used in the ICU.
Dr. Bell said that was still a good idea.
“Anytime something like this happens, it’s a chance to review your protocols,” he said.
Another suspected source of the infections that is still in play, however, is the deconstruction and construction around both Presbyterian and Montefiore, which sit on adjoining blocks and are linked by a pedestrian bridge.
“We always look at construction in outbreaks, not just fungal ones,” Dr. Bell said.
The CDC’s team took about 30 environmental samples inside both buildings, including surface samples from floor and ceiling tiles, baseboards, duct works, vents, air filters, even testing carpets and taking a vacuum bag used to clean up suspicious areas. Air samples were taken in suspected areas. And soil samples near the facility were also taken.
The investigation began, however, with the team of epidemiologists reviewing all of the charts for about 125 patients who had been in the transplant units at Presbyterian (where heart and lung transplants are done) and Montefiore (where liver and kidney transplants are done) between June, 2014 and September.
Then the team reviewed hundreds more charts for patients in both units going back to the beginning of 2011. The CDC would not say if any new fungal infection cases were found.
The CDC also collected samples of the isolated molds found in three of the four patients. The tests done by UPMC on the first patient to be infected, Ms. Fischer, were unsuccessful in isolating the fungus that killed her, possibly because the medication she had taken to ward it off damaged the organism, Dr. Brandt said.
Neither Dr. Bell nor Dr. Brandt were part of the on-the-ground investigation in Pittsburgh.
Dr. Bell said there is still more work to be done back at the CDC offices in Atlanta, including attempting to grow fungi from the surface, soil and air samples collected in Pittsburgh and seeing if whether they can be tied to the samples from the three patients.
The ultimate result of all of this, said CDC spokesman Tom Skinner, is the hope that the investigation into the fatal cluster of cases in Pittsburgh will benefit other hospitals and patients.
“It is important for our team to be there,” he said. “Each one of these cases is unique. But each one is an opportunity to learn something new.”
Sean D. Hamill: shamill@post-gazette.com or 412-263-2579
First Published: October 9, 2015, 4:00 a.m.
Updated: October 9, 2015, 5:21 p.m.
