Fatal Clostridium perfringens sepsis from a pooled platelet transfusion

Abstract

A male patient with acute myeloid leukaemia received a pooled platelet preparation prepared by Optipress system on the last day of its shelf life. The patient collapsed after two-thirds of the contents had been transfused. Clostridium perfringens was isolated from the platelet bag within 18 h of the acute event. Metronidazole, gentamicin and Clostridium antiserum were then administered in addition to the broad spectrum antibiotics started previously. However, the patient died 4 days after the platelets were transfused. The cause of death was given as cardiovascular shock, entirely compatible with an overwhelming bacteraemic and septic episode. A coroner's verdict of accidental death due to transfusion of a contaminated unit of platelets was recorded. On subsequent investigation Cl. perfringens type A serotype PS68,PS80 (identical to that found in the platelet bag) was cultured from the venepuncture site of the arm of one of the donors who contributed towards the platelet pool. The donor had two young children and frequently changed nappies. Faecal contamination of the venepuncture site was the suspected source for the transmission of Cl. perfringens, an organism commonly found in the soil and intestinal tract of humans. This case dramatically highlights the consequences of transfusing a bacterially contaminated unit. It is vital that such incidents are investigated and reported so that the extent of transfusion-associated bacterial transmission can be monitored and preventative measures taken if possible.

The human whole blood pyrogen test – lessons learned in twenty years

“…are picked up later, and there are extra costs involved. However, anaerobic bacteria have been reported in fatal septic transfusion incidents (McDonald et al, 1998). Altogether, culture methods are still the method of choice but incapable of providing complete safety and other, especially faster, methods are sought.…”

Development, validation and applications of the monocyte activation test for pyrogens based on human whole blood

“…are picked up later, and there is extra cost involved. However, anaerobic bacteria have been reported in fatal septic transfusion incidents (McDonald et al, 1998). Altogether, culture methods are incapable of providing complete safety, and other, especially quicker methods, are sought.…”

Transfusion of pooled buffy coat platelet components prepared with photochemical pathogen inactivation treatment: the euroSPRITE trial

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