Two septic transfusion reactions presenting as transfusion-related acute lung injury from a split plateletpheresis unit

Abstract

Objectives: We report two simultaneous cases of Staphylococcus aureus sepsis initially consistent with and diagnosed as transfusion-related acute lung injury. The sepsis in both cases resulted from transfusion of two split products from a single contaminated plateletpheresis unit. In each case, the platelets were given along with numerous other blood products during posterior spine surgery. The discussion includes presentation, clinical course, diagnosis, and similarities between sepsis and transfusion-related acute lung injury. The cases and discussion highlight the importance of considering sepsis as part of the differential for any patient believed to have transfusion-related acute lung injury with clinical features of sepsis.

Data sources: Data were collected from the patients' electronic medical records and the hospital laboratory medicine database.

Conclusions: Our cases highlight the importance of vigilant investigation in patients suspected of transfusion-related acute lung injury, as septic transfusions are easily missed and may mimic or coexist with transfusion-related acute lung injury. Sepsis should be strongly considered whenever clinical features such as hypotension, leucopenia, and fever are noted in patients with suspected transfusion-related acute lung injury. In comparison to patients receiving red blood cells or plasma, platelet transfusion recipients are at a greater risk for sepsis from a contaminated unit. Patients developing sepsis from a contaminated blood product may meet the clinical definition of transfusion-related acute lung injury. In such cases, if the clinical syndrome is attributed solely to transfusion-related acute lung injury and bacterial sepsis is not suspected, the correct diagnosis may be missed or delayed. Consequently, appropriate treatment for sepsis would also be delayed or not provided and likely result in increased morbidity and mortality.

Figure 1

Time course of the white blood count (WBC) in peripheral blood of the two patients is presented. Above each graph, the markers displayed on each timeline note the transfusion of each red blood cell (RBC), fresh frozen plasma (FFP), and platelet (PLT) unit. The asterisk (*) corresponds to the time at which the contaminated unit of platelets was transfused. It should be noted that the transfusion of colloid and salvaged red blood cells are not displayed.

Figure 2

(A) Giemsa-Wright stained blood smear at 100× magnification from a CBC sample (Case 1) one hour after receiving the contaminated platelet unit. Note the bacterial cocci present within the leukocyte. This smear was performed to obtain a more accurate manual platelet count as the CBC analyzer noted platelet clumps. (B) The recovered platelet bag approximately 24 hours post-infusion (Case 2), revealing a small clump within the unit tubing (arrow), suggestive of bacterial contamination. (C) Gram stain at 100× from the recovered platelet bag (Case 2) showing clumps of gram-postive cocci in clusters, consistent with a Staphylococcus species. (D) Concentrated Giemsa-Wright stain at 100× from the same recovered platelet bag (~24 hours post-infusion), again showing clumps of cocci consistent with Staphylococcus.