McDonald C P, Hartley S, Orchard K, Hughes G, Brett M M, Hewitt P E, Barbara J A
National Blood Service, North London, UK.
Transfus Med. 1998 Mar;8(1):19-22. doi: 10.1046/j.1365-3148.1998.00120.x.
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.
一名急性髓系白血病男性患者在血小板制剂保质期的最后一天接受了通过Optipress系统制备的混合血小板制剂。在输注了三分之二的制剂内容物后，患者突然倒下。在急性事件发生后的18小时内，从血小板袋中分离出产气荚膜梭菌。除了之前开始使用的广谱抗生素外，随后还给予了甲硝唑、庆大霉素和产气荚膜梭菌抗血清。然而，患者在输注血小板4天后死亡。死亡原因被判定为心血管休克，这与严重的菌血症和败血症发作完全相符。验尸官记录的死因是输注受污染的血小板单位导致意外死亡。在随后的调查中，从参与制备血小板池的一名献血者手臂的静脉穿刺部位培养出了A型产气荚膜梭菌PS68、PS80血清型（与在血小板袋中发现的相同）。该献血者有两个年幼的孩子，经常更换尿布。静脉穿刺部位的粪便污染被怀疑是产气荚膜梭菌传播的来源，产气荚膜梭菌是一种常见于土壤和人类肠道中的细菌。该病例显著凸显了输注受细菌污染的单位所带来的后果。对这类事件进行调查和报告至关重要，以便能够监测输血相关细菌传播的程度，并在可能的情况下采取预防措施。
