An Unusual Case of Transfusion Related Acute Lung Injury

Transfusion-related acute lung injury (TRALI) is a serious pulmonary complication that can develop during or within 6 h of blood transfusion. The incidence of TRALI is estimated to occur with 1 in 4500–5000 transfusions and has a fatality rate of 5%–50% during the initial acute disease progression. However, with appropriate supportive care patients surviving the acute insult have not been reported to develop pulmonary fibrosis. A female patient in her 60s with no significant past medical history was admitted to our institution for spine surgery. Her preoperative chest xray was normal. On post-operative day 3, she received 2 RBC units and, 2 h later, developed respiratory distress with diffuse interstitial infiltrates concerning for TRALI. The blood supplier was alerted and extensive serologic and historic evaluation of the patient and blood donors was performed. There was no evidence of left atrial hypertension, congestive heart failure or volume overload. She required progressively more invasive ventilation modalities culminating with mechanical ventilation, 40 h after initial onset of respiratory distress. Her condition necessitated mechanical ventilation for 6 days. Clinical improvement allowed successful extubation and transfer out of the ICU with improvement of bilateral infiltrates on chest radiographs. Unfortunately, 2 days later, she developed acute respiratory failure and was reintubated. Computerized tomography scan revealed findings consistent with acute respiratory distress syndrome (ARDS). She expired 6 weeks after her initial TRALI presentation from unremitting progressive pulmonary fibrosis. Multiple studies including autoimmune and infectious workup were negative. Serum from RBC donors tested negative for anti-HLA or HNA antibodies. The patient's serum tested positive for numerous Class I and II anti-HLA antibodies with high mean fluorescent intensity. HLA typing of blood donors has not been performed to date (Table 1). TABLE 1.