Record number:
1000
Adverse Occurrence type:
MPHO Type:
Time to detection:
45 minutes
Alerting signals, symptoms, evidence of occurrence:
Patient with acute myeloid leukaemia received 3-5 mL of an irradiated, leukoreduced 5 day old apheresis platelet unit; transfusion stopped within 15 minutes due to clogged filter. Over next 45 minutes, patient had fever to 103.9 F, rigors, and tachycardia. Sample from residual unit grew C. perfringes. Patient was on antibiotics at time of transfusion and recovered from incident.
Demonstration of imputability or root cause:
Patient was not culture positive. However, in addition to residual unit being culture positive, PLT co-component of culture-negative donation screening was intercepted on storage day 5, was visibly cloudy, and also grew C. perfringes.
Imputability grade:
2 Probable
Keywords:
Suggest references:
Eder AF et al. Clostridium perfringes in apheresis platelets: an unusual contaminant underscores the importance of clinical vigilance for septic transfusion reactions. Transfusion 2014;54:857-862.