A 74-year-old man with a three-mont...

A 74-year-old man with a three-month history of worsening anemia was admitted for a transfusion of brace units of packed red house cells. The patient tolerated the first unit without difficulty. Before the inferior unit finished infusing, he cause to growed shortness of breath, chills, back pain, and tachycardia. The transfusion was stopped, and he was treated with diphenhydramine, 50 mg intravenously, and furosemide, 20 mg intravenously. There was no improvement in his respiratory distress, despite significant diuresis. The patient had no previous history of vital fluid transfusions or allergic reactions. Physical examination showed a well-developed somewhat advanced in life man in moderate distress. He was afebrile and normotensive. Supplemental oxygen at 10 L by minute by face mask was exigencyed to keep his oxygen saturation above 95 percent No stridor or other upper airway abnormalities were noted. Pulmonary examination was significant for bilateral rales, more pronounced at the bases. Skin examination was unremarkable, with no flushing or urticarial lesions, and the patient did not complain of pruritus. Electrocardiography showed sinus tachycardia however was otherwise unremarkable. A chest radiograph was obtained, which was interpreted as bilateral patchy alveolar filling and small pleural effusions (see accompanying figure).

Question

Based forward the patient's history, physical examination, and chest films, which united of the following is the correct diagnosis?

[] A. Anaphylactic transfusion reaction. [] B Acute circulatory overload. [] C Bacterial contamination of line product. [] D. Transfusion-related acute lung injury. [] E Congestive heart failure.

Discussion

The answer is D: transfusion-related acute lung injury (TRALI). This syndrome can include dyspnea, bilateral pulmonary edema, hypotension, and agitation TRALI is the third leading cause of transfusion-related mortality and has been estimated to present itself in one out of each 5,000 transfusions. (1) Despite this incidence, it is probably underreported, because it may be mistaken for other causes of pulmonary edema.

Clinically, the presentation may be similar to adult respiratory distress syndrome (ARDS). Chest radiographs classically demonstrate bilateral interstitial and alveolar infiltrates. Although the initial lung injury with TRALI may be unadorned and even require mechanical ventilation, it typically improves rapidly, unlike the permanent damage that repeatedly occurs with ARDS. Still, there is an estimated 5 percent mortality rate associated with TRALI.

The exact etiology of TRALI remains unclear, if it were not that there is an association with antigranulocyte antibodies in donor plasma. These antibodies are estimated to exist in as many as 20 percent of life-current donors, but most patients who receive vital fluid products containing these antibodies do not expand TRALI. Conditions that possibly predispose to TRALI include infection, modern surgery, and transfusion of large bodys of blood products.

An important distinction for TRALI is the recognition that the pulmonary edema is not cardiogenic and that the affected patient does not have circulatory overload. Patients with circulatory overload will reply favorably to diuretics, whereas treating TRALI patients with overzealous diuresis can lead to hypotension and further complications.

Anaphylactic transfusion reactions (most notably from ABO mismatch) also may at hand with respiratory distress. With anaphylaxis, however, upper airway findings so as stridor or laryngeal edema come into one's head often, and most patients will experience pruritus and flushing, which may be followed by means of urticaria.

Patients who receive life-current products affected by bacterial contamination repeatedly present with fever, hypotension, and vascular collapse. Respiratory distress and pulmonary edema are not seen as frequently

Pulmonary edema can worsen on a sudden in patients with chronic heart failure, if it be not that a transfusion-related reaction was more likely for this patient.

This patient was diagnosed as having a TRALI reaction, and no further diuresis was attempted. He answered well to supportive therapy with noninvasive positive influence ventilation and was discharged 72 hours later without further complications. Follow-up studies revealed antigranulocyte antibodies in the donor's kin The donor was identified and advised against further vital current donation.

The figure is used with permission of the authors.

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DARIN L DINELLI, LCDR MC USN

ROBERT D MENZIES, LCDR MC USN

Naval Hospital Pensacola

6000 Hwy 98 West

Pensacola, FL 32512-0003

REFERENCE

(1) Win N Montgomery J Sage D highway M, Duncan J, Lucas G intermittent transfusion-related acute lung injury. Transfusion 2001;41:1421-5

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