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Recognizing a Septic Transfusion Reaction

Case Study

Case Study:

Clinical Challenge in Recognizing a Delayed Septic Transfusion Reaction

Quality Improvement After Multiple Fatal Transfusion-Transmitted Bacterial Infections1

Contaminated platelet bag

Contaminated platelet bag showing Staphlyococcus aureus.

  • A neutropenic leukemia patient received routine outpatient platelet and RBC transfusions.
  • Platelets and first RBC unit were transfused without incident, within minutes of starting the second RBC transfusion patient developed rigors, transfusion was stopped.
  • Symptoms resolved temporarily, but two hours later was admitted for neutropenic fever.
  • Given timeline and neutropenia, contamination of the platelet unit was not suspected, and the co-component platelet unit was not quarantined.
  • The following morning, visual inspection of the co-component revealed “cotton ball”-like flocculation of Staphylococcus aureus, testing revealed a match to the infection in the patient.

Case study transfusion reaction

Additional Resources

Septic transfusion poster

Download an educational poster on diagnosis of a septic transfusion reaction