FATAL CLOSTRIDIUM-PERFRINGENS SEPSIS FROM A POOLED PLATELET TRANSFUSION

A male patient with acute myeloid leukaemia received a pooled platelet preparation prepared by Opti-press(TM) press system on the last day o f its shelf life. The patient collapsed after two-thirds of the conten ts 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 b road spectrum antibiotics started previously. However, the patient die d 4 days after the platelets were transfused. The cause of death was g iven as cardiovascular shock, entirely compatible with an overwhelming bacteraemic and septic episode. A coroner's verdict of accidental dea th due to transfusion of a contaminated unit of platelets was recorded . On subsequent investigation CI. perfingens type A serotype PS68,PS80 (identical to that found in the platelet bag) was cultured from the v enepuncture site of the arm of one of the donors who contributed towar ds 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 an d reported so that the extent of transfusion-associated bacterial tran smission can be monitored and preventative measures taken if possible.