SHOT Annual Report 2009 - Serious Hazards of Transfusion

Case Histories
TRALI probable
Case 1
Probable TRALI following transfusion of RBC OA to treat symptomatic tumour anaemia
A man had disseminated rectal cancer plus severe coronary artery disease, left ventricular hypertrophy, and bilateral
peripheral oedema extending to just below his knees. He was transfused with 3 RBC OA units. Six hours later during
transfusion of the third unit he developed chills, rigors, breathlessness, wheeze, and his JVP was raised. He died an
hour later. At postmortem he had severe pulmonary oedema with no evidence of MI or PE. Lung histology showed
increased numbers of neutrophils in the interstitial fluid.
Investigations revealed that the female RBC donor of the third unit had multiple HLA class I and class II antibodies
concordant with patient HLA-B60, DR13, DR52 and DQ6. The implicated blood pack was also cultured for bacteria
and grew Enterobacter species, Pantoea species and Enterococcus faecalis but, because the blood pack had been
unspigoted, these findings were considered most likely to have been due to contamination (as discussed in the SHOT
Annual Report 2008, page 128). This case was assessed as probable TRALI because cardiac failure may also have
contributed to the pulmonary oedema.
TRALI highly likely
Case 2
TRALI follows receipt of female FFP during treatment of TTP
A patient received 4 units FFP and was being transferred to another hospital between 2 and 6 hours later when she
suddenly developed respiratory distress. The ambulance diverted to the nearest hospital where the patient became
increasingly hypoxic and hypotensive. Her chest was described as ‘bubbly’ and her CXR as ‘bilateral white-out’. She
suffered cardio-respiratory arrest from which she was successfully resuscitated but required mechanical ventilation for
2 days. She made a full recovery from this event.
One female donor was found to have multiple HLA class I antibodies including HLA B8 antibodies concordant with this
patient. This case was assessed as highly likely to be TRALI.
TRALI possible
Case 3
Middle-aged woman developed possible TRALI after transfusion to treat variceal bleeding
This patient had cirrhosis, portal hypertension and a large gastric varix. She was admitted with Hb 3.7 g/dL following
upper GI bleeding. She received 4 packs of RBC over the next 3 days for continued GI bleeding. Six days after admission
she bled further and E. coli was cultured from her urine. She had repeat endoscopy and injection of a bleeding gastric
varix. Terlipressin was commenced and she was transfused with 1 unit of male RBC OA which was discontinued due to
a febrile reaction. Five hours later transfusion was recommenced. After 1 male FFP and 2 male RBC she developed a
drop in O 2
saturation from 100% to 94% and was started on O 2
support 4 L/min with improvement. She then received
1 male FFP and 2 female RBC OA units. Her respiratory rate gradually increased and CXR around 9 hours after the
initial drop in O 2
level was reported as ‘suboptimal inspiration... but there is strong impression of bilateral airspace
shadowing compatible with consolidation’. Terlipressin was discontinued with some symptomatic improvement. A
few hours later she had cardiopulmonary arrest and resuscitation was unsuccessful. Postmortem examination found
pulmonary oedema and early stage ARDS but no evidence of MI.
The 2 female RBC donors were tested: the male donors were excluded from investigation. One female donor had HLA
class II antibodies with concordance at HLA-DR51 and DQ6 but this donation had not been commenced until 2 hours
after the patient’s respiratory deterioration had already begun. The other female donor did not have concordant HLA
or HNA antibodies. This case was assessed as possible TRALI due to the timing of events and the presence of other risk
factors for respiratory deterioration.
13. Transfusion-Related Acute Lung Injury (TRALI) 113