Fatal Clostridium perfringens sepsis from a pooled platelet transfusion
Fatal Clostridium perfringens sepsis from a pooled platelet transfusion
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.
Acute Disease, Adult, Anaerobiosis, Arm, Bacteremia, Bacterial Toxins, Blood Donors, Blood Platelets, Blood Preservation, Clostridium perfringens, Equipment Contamination, Fatal Outcome, Feces, Gas Gangrene, Hand Disinfection, Humans, Infection Control, Leukemia, Myeloid, Male, Phlebotomy, Platelet Transfusion, Shock, Septic, Skin, Case Reports, Journal Article
19-22
McDonald, C P
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Hartley, S
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Orchard, K
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Hughes, G
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Brett, M M
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Hewitt, P E
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Barbara, J A
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March 1998
McDonald, C P
fd9f9d68-ad7a-4e82-a88d-a2dbc623ce91
Hartley, S
8f815cea-7912-4750-97c9-5a4664362c86
Orchard, K
794654ab-d6cc-488a-ac11-c9217433c7a2
Hughes, G
223e0e8a-0229-4f07-ad64-5b56244f0a14
Brett, M M
16dc26b9-204a-495e-896b-fd35e47e54e8
Hewitt, P E
9f2d9070-7fd5-42ed-bf88-428018011259
Barbara, J A
7d4bed4a-3f94-41be-8797-12b3b980364c
McDonald, C P, Hartley, S, Orchard, K, Hughes, G, Brett, M M, Hewitt, P E and Barbara, J A
(1998)
Fatal Clostridium perfringens sepsis from a pooled platelet transfusion.
Transfusion Medicine, 8 (1), .
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.
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More information
Published date: March 1998
Keywords:
Acute Disease, Adult, Anaerobiosis, Arm, Bacteremia, Bacterial Toxins, Blood Donors, Blood Platelets, Blood Preservation, Clostridium perfringens, Equipment Contamination, Fatal Outcome, Feces, Gas Gangrene, Hand Disinfection, Humans, Infection Control, Leukemia, Myeloid, Male, Phlebotomy, Platelet Transfusion, Shock, Septic, Skin, Case Reports, Journal Article
Organisations:
Cancer Sciences
Identifiers
Local EPrints ID: 411600
URI: http://eprints.soton.ac.uk/id/eprint/411600
ISSN: 0958-7578
PURE UUID: 598db8db-9089-413c-bd86-517a1db59006
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Date deposited: 21 Jun 2017 16:31
Last modified: 09 Jan 2022 03:09
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Contributors
Author:
C P McDonald
Author:
S Hartley
Author:
K Orchard
Author:
G Hughes
Author:
M M Brett
Author:
P E Hewitt
Author:
J A Barbara
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