When Seattle Children’s Hospital revealed last month that 14 children dating back to 2001 had been infected with Aspergillus mold, six of them fatally, the cases had an unusual feature in common.
They all involved patients who had contracted the infection during surgery, ostensibly as spores from the fungus contaminated the operative wound. It is the rarest way of getting such an infection, according to medical experts, that almost by definition can only happen in a hospital.
That count apparently wouldn’t have included Aiden Wills, a 3-year-old boy who came to Children’s for a bone-marrow transplant. After a 2009 procedure, he was diagnosed with an Aspergillus lung infection that hampered his treatment, according to a lawsuit filed by his family and others. He died two months later.
His case represents the most common way of getting an Aspergillus infection, by breathing in spores from the mold. For patients with weakened immune systems, such an infection can be a “game over” scenario, as the mother of one seriously ill transplant patient recalled doctors telling her.
Children’s has not cited any such cases as it has explored the causes of the 14 infections it has identified, which the prestigious institution has linked to an inadequate air-filtration system in its operating rooms.
Aspergillus infections of any kind are highly uncommon. Yet in several hundred cases statewide, patients have been diagnosed with the infection after checking in to Children’s and other hospitals, according to a Seattle Times analysis of discharge data tracked by the state Department of Health.
Among nearly 6.8 million hospital stays in the state from 2009 through the first half of 2019, hospitals reported Aspergillus infections in just 4,159 cases, the data shows.
In more than 90% of these stays, the hospitals reported that patients had the infections at the time they were admitted.
But in 355 cases at 35 hospitals, in stays ranging from eight days to nine months, the diagnoses were made after patients were admitted. Regulators and hospitals’ infectious-disease experts said they do not think patients in these cases got the infections from a hospital. Determining this can only be done by reviewing a patient’s medical records, and it is not always clear-cut.
The condition can be difficult to identify, and a patient could arrive with indications of an Aspergillus infection but not be diagnosed until later. Complicating efforts to pinpoint the source is the nature of Aspergillus itself: a mold common indoors and outdoors, which can colonize a human host without always causing symptoms.
“We don’t have any evidence to suggest that there have been unrecognized cases of health care-associated Aspergillus at any health care facility in King County,” said James Apa, a spokesman for Public Health — Seattle & King County.
Steve Pergam, the medical director of infection prevention for the Seattle Cancer Care Alliance, stressed that hospitals go to great lengths to protect vulnerable patients from infection. Patients, he said, “should rest assured that we’re spending a significant amount of time protecting those environments, so when they come in they should feel safe.”
Lisa Stromme Warren, a spokeswoman for the state Department of Health, said the discharge data can’t show where an Aspergillus infection originated.
“You can’t differentiate people who are colonized with the fungus who then develop disease from those who acquire the infection within the health care setting,” she said.
The Times shared its findings with hospitals, some of which reviewed cases of Aspergillus infections diagnosed after a patient was admitted. The hospitals uniformly said their reviews found no reasons to suspect patients got the infection in the hospital, although some physicians acknowledged it can be hard to say with certainty.
Most people don’t get sick from breathing in Aspergillus. But for those with weakened immune systems — notably cancer and transplant patients — the mold can grow inside a person’s sinuses or airways and cause a range of symptoms, from an allergic reaction to fever and trouble breathing in the most serious cases.
Hospitals aren’t required to report Aspergillus infections to local or national health regulators unless there is an outbreak. In the past decade, Children’s is the only hospital that has reported Aspergillus cases to King County and Seattle health authorities.
“Zero immune system”
The disclosures by Children’s have brought an intense focus on Aspergillus infections. Public Health — Seattle & King County is convening experts to create new requirements for reporting the infections in certain cases.
The Times’ analysis found 25 hospital admissions at Children’s since 2011 in which a patient was diagnosed with an Aspergillus infection that wasn’t reported as present at the time of admission.
The analysis would not include cases where a patient was treated and discharged but not diagnosed with an Aspergillus infection until a subsequent hospital stay. One such patient, Anna Christina Ventura Hernandez, came to Children’s in 2014 for brain surgery and returned home to Wenatchee — until her condition worsened and the teenager was airlifted back to the hospital and diagnosed with an Aspergillus infection, according to an ongoing lawsuit that claims she contracted the infection during her first stay at the hospital. She died the next month, and death records list an Aspergillus infection in the brain as a contributing cause.
Children’s has said it would not comment on the litigation and declined to answer questions for this article. “We are working diligently to resolve these issues, including the claims that have been brought against Seattle Children’s related to past surgical site infections,” a spokeswoman said. The hospital has closed most of its operating rooms to install custom-built air-filtration systems.
Earlier this month, lawyers filed a complaint against Children’s seeking to represent a class of former patients who “contracted any version of Aspergillus mold-related illness caused by exposure” within the hospital. The lawsuit currently names five patients, including Wills and Ventura Hernandez.
“They are overly narrow in looking at the problem here,” Karen Koehler, lead attorney representing the families, said of Children’s disclosure of the 14 surgery-related infections. “We don’t trust Children’s to make that count.”
Not all families of former patients who got the infection believe the hospital was at fault. Carrie Windham, who lives outside San Antonio, Texas, had brought her 10-year-old son Rowan to Seattle Children’s in 2016 for a transplant that was his last chance to live.
Born with a rare disorder that prevented his bone marrow from producing enough infection-fighting cells, Rowan was the kind of patient particularly vulnerable to airborne molds like Aspergillus. He had beaten the odds many times, but if he got a fungal infection in his lungs, his mother recalls doctors saying, “It’s game over.”
After two transplants, the red-haired boy with a splash of freckles, who was given to declaring daily “I love my life,” died of heart failure in December 2016. An infection from Aspergillus mold in his lungs was listed as a contributing cause, state death records show.
Carrie Windham doesn’t fault the hospital, whose staff, she said, worked relentlessly to save her son’s life.
“He had zero immune system,” she said. With his survival in doubt, Rowan ventured to the hospital’s rooftop garden to experience being outdoors. The infection could have come from anywhere, she said.
“I feel so bad for the families,” she said of the Aspergillus infections disclosed by Children’s, but she can’t bring herself to say a negative word about the hospital.
She thinks of the time Rowan’s heart stopped and Children’s staff worked to save him — successfully — and how her son reached up and wiped away her tears. She was the donor for his first bone-marrow transplant and remembers how, after it failed, some 30 hospital staff members bought shirts with one of the boy’s signature mantras, “If you can’t see the good, make the good.”
Windham recently published a book about Rowan’s legacy, “Holding on to Hope,” and listed the doctors, nurses and staff of Children’s in the dedication.
Present on admission?
In the Department of Health’s statewide discharge data, one hospital stands out for diagnosing Aspergillus infections: University of Washington Medical Center (UWMC).
The hospital, operated by UW Medicine, reported 157 cases over a decade in which an infection wasn’t listed as present on admission, including patients of Seattle Cancer Care Alliance (SCCA).
UWMC and SCCA also reported by far the most hospitalizations with a diagnosis of an Aspergillus that was present on arrival, with more than 1,300.
Hospital officials say the numbers reflect UWMC’s role in caring for an outsized share of critically ill cancer and organ-transplant patients — whose weakened immune systems make them most vulnerable — and the advanced tools it has to detect the infections.
Following the methodology used by The Times, doctors at UWMC and SCCA said they conducted detailed reviews of medical charts of 40 to 50 cases from 2016 through 2018. They don’t believe any of the Aspergillus infections were acquired at the hospital.
More than half had “clear evidence of having Aspergillus on arrival,” but it wasn’t diagnosed until later, said Tom Staiger, UWMC’s medical director. In other cases, patient charts were coded with an Aspergillus diagnosis but doctors concluded the patients probably didn’t have the condition, he said.
“Then there was a group where, while we couldn’t be sure one way or the other, we didn’t find any clear evidence that any of those individuals had hospital-acquired Aspergillus.”
Katrina Streiff, a 71-year-old psychiatrist, developed the infection while being treated for leukemia at UWMC, according to her husband, Jim Laurino, and died in 2016. He doesn’t blame the hospital.
“The problem of course was that she had no neutrophils,” he said, referring to the white blood cells that fight infection. He said the hospital had “a very strict and careful isolation regime,” requiring him to wear a gown, gloves and a mask to visit her. After her death, Streiff’s family made her favorite hazelnut macaroons for UWMC’s staff.
Yet some still have questions. Mary Whitley, who had a rare blood disorder, spent about three months at Swedish Hospital on First Hill in 2016 receiving chemotherapy and donor plasma, her husband said.
While at the hospital, she developed an Aspergillus infection, according to her husband, Kirk Whitley. She died in May 2016 of multiple organ failure. “Pulmonary aspergillosis” is listed as a contributing cause of death. Her husband assumes she got the infection in the hospital.
“She didn’t go there with it, and that’s where she was for her last three months,” he said.
Swedish’s First Hill and Ballard hospitals reported 33 instances over a decade in which an Aspergillus infection was diagnosed after admission — the second-highest in the state, according to The Times’ analysis.
As with UWMC, Swedish also had a large number of patients who arrived with Aspergillus, which the hospital attributed to caring for patients with weakened immune systems.
The discharge data analyzed by The Times does not include patient names and identifying details, and it isn’t known if Whitley was among the 33 cases the newspaper found. Hospitals are restricted by privacy laws from commenting on individual cases.
Swedish said it thoroughly reviewed data back to 2015 and found “no indication that transmission may have occurred during a sterile or operative procedure.” Swedish says it monitors all serious Aspergillus infections, adding, “We have never seen any patterns or unusual infection events to indicate we have a problem with hospital Aspergillus exposures.”
A life altered
Seattle Children’s was confident for years that it didn’t have an Aspergillus problem. Even when three patients — ages 1 month, 6 months and 3 years — developed infections after undergoing heart surgery, the hospital suspected a dirty nitrogen tank as the culprit.
For almost three years, it fought allegations in court that the hospital’s HVAC system caused an Aspergillus infection in a 12-year-old girl who underwent brain-tumor surgery in 2002. The case settled in 2008.
The girl, Shanna Patnode, is now a woman of 29. She uses a catheter to go to the bathroom, a straw to drink because swallowing is hard, and special glasses to mitigate her double vision. She has multiple walkers — for ordinary use and for navigating narrow spaces. She lives with her parents and requires 24-hour care.
Her sense of humor remains intact.
When her high school had coffee stirrers but no straws, she complained, “Life sucks, bring a straw.”
Patnode takes piano and yoga lessons, and enjoys the occasional trip to a movie theater, but mostly thinks about her future week by week. When she heard about the recent infections at Seattle Children’s, she said, “I felt like an asteroid hit me.”
Children’s, asked recently about the Patnode case, said it “is deeply sorry that recent events have caused them additional grief.” Shanna Patnode had no reaction to the apology, but her father, Gene did.
The “so-called apology is 15 years late,” he said.
“Our entire family has to suffer through the repercussions of this for the rest of our lives,” he said. “She never gets to have a normal life ever, neither do we.”
Editor’s Note: Seattle Children’s hospital is a funder of The Seattle Times’ Traffic Lab. The Times retains full control over news content.