BACKGROUND: Hematopoietic cell transplantation (HCT) is performed in more than 25,000 patients annually. Clinically significant bacterial transmission from HCT products is rare.

CASE REPORT: A 36-year-old male of Asian descent with chronic myelogenous leukemia developed sepsis leading to acute renal failure and disseminated intravascular coagulation during infusion of matched unrelated donor bone marrow. This product later tested positive for Bacillus cereus.

DISCUSSION: This HCT product traveled 31 hours at room temperature before arriving at the transplant center. Reducing transport times, transporting at 4°C, and enhancing bacterial surveillance of HCT products may increase the ability to detect bacterial proliferation from transport.

CONCLUSION: To prevent a similar case in the future, we will begin Gram staining all HCT products in transit more than 24 hours to alert physicians of the need for prophylactic antibiotic therapy.