Transfusion-related acute lung injury (TRALI)

Case contributed by Yaïr Glick

Presentation

Developed shortness of breath several hours after receiving several units of platelets.

Patient Data

Age: 60 years

Previous x-ray, 2 days earlier - lungs are clear.

Lungs show bilateral diffuse coarse reticular pattern and prominent hila.
Slight medialization of left costophrenic angle, probably representing small pleural effusion.
Cardiac shadow not widened, taking into account patient positioning.
Calcific aortic knuckle.

CT chest-abdomen-pelvis (abdomen and pelvis not included here; no pathology of concern) done shortly after intubation.

Properly placed ETT and NGT.

Paraseptal emphysema, mostly in upper lung lobes.
Large areas of thickened intralobular septa on a background of ground glass opacities (i.e. "crazy paving") in all pulmonary lobes. Small subpleural consolidation in left lower lobe (LLL). Bilateral pleural effusions, small-to-moderate amount on right and small amount on left.

Repeat chest x-ray:

Right jugular venous catheter with tip in SVC. Properly placed ETT and NGT.
Lungs have largely cleared, with residual mild pulmonary edema appearing as peribronchial cuffing.

Case Discussion

Was diagnosed with leptospirosis after having complained of weakness and myalgia, without arthralgia. History of COPD due to heavy smoking. During hospitalization, thrombocyte levels dropped to 14K/uL (true thrombocytopenia), probably due to sepsis. Received 6 units of thrombocytes. Approximately two hours later, developed severe shortness of breath.
X-ray chest showed course reticulations. Intubated and ventilated. CT chest-abdomen-pelvis showed diffuse crazy paving; no intra-abdominal pathology of concern.
Since all other parameters remained unchanged (e.g. continued receiving the same antibiotics) except for the thrombocyte infusion, respiratory failure was attributed to transfusion-related acute lung injury (TRALI), for which she received steroids, in addition to the antibiotics and supportive treatment. She was weaned from ventilation after two days and released from the hospital two days later.

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