CMV IGG, IGG ANTIBODIES TO CYTOMEGALOVIRUS

MAUDE Adverse Event Report

MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a foreign,health professional,u report with the FDA on 2016-03-30 for CMV IGG, IGG ANTIBODIES TO CYTOMEGALOVIRUS manufactured by Roche Diagnostics.

Event Text Entries

[41567328] This event occurred in (b)(6).
Patient Sequence No: 1, Text Type: N, H10


[41567329] The customer questioned results for 21 patients tested for igm antibodies to cytomegalovirus (cmv igm) and igg antibodies to cytomegalovirus (cmv igg). Erroneous cmv igm or cmv igg results were identified for 14 patients. The erroneous results for were reported outside of the laboratory. This medwatch will cover cmv igg. Refer to medwatch with patient identifier (b)(6) for information on the cmv igm erroneous results. Patient 1 initial cmv igm result from the e601 analyzer was 0. 386 coi (negative). The repeat result from the mini vidas analyzer was 1. 88 (positive) and the repeat result from the architect i 1000 was 1. 93 (positive). Patient 1 initial cmv igg result from the e601 analyzer was <0. 250 au/ml (negative). The sample was repeated on an architect i 1000 and the result was 19. 6 (positive). The cmv igg result from the mini vidas method was <4. 00 ua/ml (negative). On (b)(6) 2016 a new sample was obtained from patient 1 and the initial cmv igm result from the e601 analyzer was 0. 170 coi (negative). The sample was repeated on an architect i 1000 and the result was 76 (positive). The cmv igm result from the mini vidas method was 0. 120 (negative). The initial cmv igg result from the e601 analyzer was 16. 4 au/ml (positive). The sample was repeated on an architect i 1000 and the result was 0. 390 (negative). The cmv igg result from the mini vidas method was 9 ua/ml (positive). On (b)(6) 2016 patient 2 initial cmv igm result from the e601 analyzer was 0. 657 coi (negative). The repeat from the mini vidas analyzer was 1. 83 (positive). On (b)(6) 2016 patient 3 initial cmv igm result from the e601 analyzer was 0. 534 coi (negative). The result from the mini vidas instrument was 1. 280 (positive). The result from the architect i 1000 was positive; the actual result was not provided. On an unknown date patient 4 initial cmv igg initial result from the e601 analyzer was 1. 52 au/ml (positive). The repeat result from the architect i 1000 was 4. 3 (negative). On an unknown date patient 5 initial cmv igm initial result from the e601 analyzer was 0. 281 coi (negative). The repeat result from the architect i 1000 was 2. 09 (positive). The repeat result from the mini vidas analyzer was 1. 32 (positive). On an unknown date patient 6 initial cmv igm initial result from the e601 analyzer was 0. 644 coi (negative). The repeat result from the architect i 1000 was 2. 09 (positive). The repeat result from the mini vidas analyzer was 1. 32 (positive). On an unknown date patient 7 initial cmv igm initial result from the e601 analyzer was 0. 381 coi (negative). The repeat result from the architect i 1000 was 1. 51 (positive). The repeat result from the mini vidas analyzer was 1. 21 (positive). On an unknown date patient 8 initial cmv igm initial result from the e601 analyzer was 0. 192 coi (negative). The repeat result from the architect i 1000 was 2. 56 (positive). The repeat result from the mini vidas analyzer was 0. 08 (negative). On an unknown date patient 9 initial cmv igm initial result from the e601 analyzer was 0. 35 coi (negative). The repeat result from the architect i 1000 was 0. 91 (positive). The repeat result from the mini vidas analyzer was 1. 33 (positive). On an unknown date patient 10 initial cmv igm initial result from the e601 analyzer was 0. 364 coi (negative). The repeat result from the architect i 1000 was 5. 42 (positive). The repeat result from the mini vidas analyzer was 1. 08 (positive). On an unknown date patient 11 initial cmv igm initial result from the e601 analyzer was 0. 219 coi (negative). The repeat result from the architect i 1000 was 0. 93 (positive). The repeat result from the mini vidas analyzer was 0. 17 (negative). On an unknown date patient 12 initial cmv igm initial result from the e601 analyzer was 0. 045 coi (negative). The repeat result from the architect i 1000 was 3. 25 (positive). The repeat result from the mini vidas analyzer was 0. 38 (negative). On an unknown date patient 13 initial cmv igm initial result from the e601 analyzer was 0. 323 coi (negative). The repeat result from the architect i 1000 was 1. 07 (positive). The repeat result from the mini vidas analyzer was 0. 9 (positive). On an unknown date patient 14 initial cmv igm initial result from the e601 analyzer was 0. 344 coi (negative). The repeat result from the architect i 1000 was 1. 02 (positive). The repeat result from the mini vidas analyzer was 0. 07 (negative). It was noted that a primary infection was missed for patient 1 & 3 due to the negative cmv igm results, however, no adverse event occurred. Patient 2 was not adversely affected. No adverse event was reported for patients 4 through 14. The e601 analyzer serial number was (b)(4).
Patient Sequence No: 1, Text Type: D, B5


[48202910] The samples for patient 1 from (b)(6) 2015 and (b)(6) 2016 were submitted for investigation. The results from the customer were confirmed during the investigation. The samples were tested by the roche method and the mikrogen recomline method. The roche results and recomline results were comparable. Both the roche assay and the recomline assays do not detect significant cmv-specific igm titers in the samples. For this patient, a seroconversion for igm was not detected. Missing the igm seroconversion of a patient with 2 independent assays at the same time is rare but cannot be excluded for this patient. The sample for patient 2 from (b)(6) 2016 was submitted for investigation. The samples were tested by the roche method and the mikrogen recomline method. The customer results could not be confirmed during the investigation. Cmv-specific igg antibodies were detected in both the roche cmv igg assay and the recomline cmv igg assay and found to be of high avidity. The high avidity of the detected igg antibodies indicates a remote infection with cmv. When samples are obtained during the declining phase of the igm response, assays from different manufacturers are likely to produce discrepant results; however, a reliable diagnosis of the cmv status can be obtained by assessing the igg status in combination with the igg avidity. A general decline of the cmv igm results was not confirmed. Internal quality assurance prior to product release and real time monitoring following product release guarantee constant performance. Comparative measurements minimize performance variance between different lots.
Patient Sequence No: 1, Text Type: N, H10


[50750865]
Patient Sequence No: 1, Text Type: N, H10


MAUDE Entry Details

Report Number1823260-2016-00377
MDR Report Key5534903
Report SourceFOREIGN,HEALTH PROFESSIONAL,U
Date Received2016-03-30
Date of Report2016-07-21
Date of Event2015-10-26
Date Mfgr Received2016-03-09
Date Added to Maude2016-03-30
Event Key0
Report Source CodeManufacturer report
Manufacturer LinkY
Number of Patients in Event0
Adverse Event Flag3
Product Problem Flag3
Reprocessed and Reused Flag3
Health Professional3
Initial Report to FDA3
Report to FDA3
Event Location3
Manufacturer ContactNA MICHAEL LESLIE
Manufacturer Street9115 HAGUE ROAD NA
Manufacturer CityINDIANAPOLIS IN 46250
Manufacturer CountryUS
Manufacturer Postal46250
Manufacturer Phone3175214343
Manufacturer G1ROCHE DIAGNOSTICS GMBH
Manufacturer StreetSANDHOFERSTRASSE 116 NA
Manufacturer CityMANNHEIM (BADEN-WURTTEMBERG) 68305
Manufacturer CountryGM
Manufacturer Postal Code68305
Single Use3
Previous Use Code3
Removal Correction NumberNA
Event Type3
Type of Report3

Device Details

Brand NameCMV IGG, IGG ANTIBODIES TO CYTOMEGALOVIRUS
Generic NameENZYME LINKED IMMUNOABSORBENT ASSAY, CYTOMEGALOVIRUS
Product CodeLFZ
Date Received2016-03-30
Model NumberNA
Catalog NumberASKU
Lot NumberASKU
ID NumberNA
OperatorHEALTH PROFESSIONAL
Device AvailabilityY
Device AgeDA
Device Eval'ed by MfgrR
Device Sequence No1
Device Event Key0
ManufacturerROCHE DIAGNOSTICS
Manufacturer Address9115 HAGUE ROAD NA INDIANAPOLIS IN 462500457 US 462500457


Patients

Patient NumberTreatmentOutcomeDate
10 2016-03-30

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