Status:
Ready to upload
Record number:
1667
Adverse Occurrence type:
MPHO Type:
Estimated frequency:
Not given
Time to detection:
4 hours
Alerting signals, symptoms, evidence of occurrence:
Low grade fever, shortness of breath, nausea, low blood pressure, shock, death.
Demonstration of imputability or root cause:
Blood culture from the patient and from the remaining platelet product in the bag grew S. Epidermidis with identical biochemical phenotype, identical minimal inhibitory concentrations, and identical ribotyping analysis.
Imputability grade:
3 Definite/Certain/Proven
Groups audience:
Keywords:
Suggest new keywords:
Staphylococcus epidermidis
pooled platelet concentrate, buffy coat platelet
ribotyping, low grade fever, shortness of breath, nausea, low blood pressure, shock, death
Reference attachment:
Suggest references:
Kou, Y Pagotto, F, Hannach, B and Ramirez-Arcos, S. Fatal false-negative transfusion infection involving a buffy coat platelet pool contaminated with biofilm-positive Staphylococcus
epidermidis: a case report. Transfusion 2015;55;2384–2389
Expert comments for publication:
This is a case of fatal sepsis from a pooled platelet concentrate that was infused into an elderly asplenic patient with chronic myelogenous leukemia. There was no acute reaction, however the patient returned to the hospital 4 hours after the transfusion with signs and symptoms of infection, became septic and died. Investigation of the case demonstrated this to be a false negative as the BacT Alert culture system did not detect the bacteria. Further investigation demonstrated that the strain of S. epidermidis is a weak biofilm former, but in the presence of platelet concentrates becomes a strong biofilm producer. This likely accounts for the false positive culture result in a bag of platelets contaminated by bacteria which had adhered to the inner surface of the platelet container.