inforMED
MalfunctionLFZ

ELECSYS CMV IGM

Received Mar 9, 2023 · Event occurred Feb 10, 2023

Report 1823260-2023-00749 · MDR key 16516443

Device

Generic name

Enzyme Linked Immunoabsorbent Assay, Cytomegalovirus

Manufacturer

Roche Diagnostics

Model number

NA

Catalog number

07027133190

Lot number

63027501

Product problems

  • False Negative Result
  • False Negative Result

Patient

Unknown

  • No Clinical Signs, Symptoms or Conditions
  • No Clinical Signs, Symptoms or Conditions

Narrative

Additional Manufacturer Narrative

CALIBRATION AND QC WERE ACCEPTABLE. THE SAMPLE WAS REQUESTED FOR INVESTIGATION.

Description of Event or Problem

THE INITIAL REPORTER QUESTIONED NEGATIVE RESULTS FOR 1 PATIENT TESTED FOR ELECSYS CMV IGG (CMV IGG) AND ELECSYS CMV IGM (CMV IGM) ON A COBAS E 801 MODULE. THIS MEDWATCH WILL COVER CMV IGM. REFER TO MEDWATCH WITH PATIENT IDENTIFIER (B)(6) FOR INFORMATION ON THE CMV IGG RESULTS. THE INITIAL CMV IGG RESULT FROM THE E801 MODULE WAS 0.180 U/ML (NEGATIVE). THE INITIAL CMV IGM RESULT FROM THE E801 MODULE WAS 0.239 COI (NEGATIVE). THE INITIAL RESULTS WERE REPORTED OUTSIDE OF THE LABORATORY. THE PATIENT WENT TO ANOTHER HOSPITAL. A NEW SAMPLE WAS OBTAINED AND THE CMV IGG AND CMV IGM RESULTS FROM THE CHORUS DIESSE METHOD WERE BOTH POSITIVE (THE ACTUAL RESULTS WERE NOT PROVIDED). THE ORIGINAL SAMPLE WAS SENT TO AN EXTERNAL LABORATORY FOR TESTING BY THE DIASORIN LIASON METHOD AND THE CMV IGG RESULT WAS 16.7 U/ML (POSITIVE) AND THE CMV IGM RESULT WAS 80.3 COI (POSITIVE). ON (B)(6) 2023 THE CUSTOMER REPEATED THE ORIGINAL SAMPLE ON THE E801 MODULE AND THE CMV IGG RESULT WAS 0.181 U/ML (NEGATIVE) AND THE CMV IGM RESULT WAS 0.240 COI (NEGATIVE). ON (B)(6) 2023 THE ORIGINAL SAMPLE WAS AGAIN REPEATED BY THE CUSTOMER WITH A CMV IGG RESULT OF 0.204 U/ML (NEGATIVE) AND A CMV IGM RESULT OF 0.241 COI (NEGATIVE). THE ORIGINAL SAMPLE ALSO UNDERWENT MOLECULAR ANTIGEN TESTING WHERE THE RESULTS WERE POSITIVE. THE E801 MODULE SERIAL NUMBER WAS (B)(4).

Additional Manufacturer Narrative

SECTION D4, CATALOG NUMBER WAS UPDATED. TWO SAMPLES FROM THE PATIENT WERE RECEIVED FOR INVESTIGATION (A SAMPLE FROM ON (B)(6)2023 AND A SAMPLE FROM ON (B)(6) 2023). THE SAMPLES WERE RUN ON AN E801 MODULE WHERE THE CMV IGG AND CMV IGM RESULTS WERE BOTH NEGATIVE. ON (B)(6) 2023: CMV IGM RESULT WAS 0.284 U/ML (NEGATIVE). CMG IGG RESULT WAS 0.176 U/ML (NEGATIVE). ON (B)(6) 2023: CMV IGM RESULT WAS 0.54 U/ML (NEGATIVE). CMG IGG RESULT WAS 0.3 U/ML (NEGATIVE). THE CUSTOMER'S RESULTS WERE REPRODUCED. THE INVESTIGATION IS ONGOING.

Additional Manufacturer Narrative

THE TWO SAMPLES WERE FURTHER INVESTIGATED BY TESTING WITH THE RECOMLINE CMV IGG ASSAY AND THE RECOMLINE CMV IGM ASSAY FROM MIKROGEN. BOTH SAMPLES TESTED POSITIVE FOR CMV IGG AND CMV IGM. THE RESULTS FROM THE INVESTIGATION SUGGEST A PRIMARY INFECTION IN THE EARLY PHASE. THE ROCHE RESULTS SHOWED INCREASING RESULTS WITH THE 2ND SAMPLE. THE NEGATIVE RESULTS FROM THE ROCHE METHOD MAY INDICATE A VERY EARLY PHASE OF INFECTION. A NEW SAMPLE FROM THE PATIENT WAS OBTAINED ON (B)(6) 2023 AND TESTED FOR CMV IGM AND CMV IGG. THE CMV IGM RESULT WAS NEGATIVE. THE SPECIFIC RESULT WAS NOT PROVIDED. THE CMV IGG RESULT WAS 2.9 U/ML (POSITIVE). THE INVESTIGATION IS ONGOING.

Additional Manufacturer Narrative

BASED ON THE INVESTIGATION RESULTS, THE REAGENTS PERFORM WITHIN SPECIFICATION. THE INVESTIGATION DID NOT IDENTIFY A PRODUCT PROBLEM.