Key Clinical Message
Transfusion-related acute lung injury (TRALI) is characterized by
non-cardiogenic pulmonary oedema and acute hypoxemia. TRALI attributed
to HLA-Ⅱ antibodies is infrequently reported in China.
Keywords: Transfusion-related acute lung injury; HLA class II
antibodies; pulmonary edema; blood transfusion
Introduction
The Food and Drug Administration
(FDA) reports that transfusion-related acute lung injury (TRALI) is the
main reason behind morbidity and mortality associated with
transfusion.1 This condition is characterized by the
sudden appearance of non-cardiogenic pulmonary edema and hypoxemia
within six hours of blood transfusion. According to data from the
International Haemovigilance (HV) Network, the morbidity rate of TRALI
is 0.0494 per 100,000 parts of blood transfused. Additionally, the
mortality rate of TRALI among the general patient population is
approximately 10-15%, reaching nearly 40% in critically ill
patients.2,3 In Chinese populations, the morbidity and
mortality rate of TRALI remains unclear due to insufficient disease
awareness, incomplete reporting systems, and HV data.
We attempt to raise awareness among
clinicians by reviewing a patient who developed TRALI after receiving
frozen plasma controlled by HLA-Ⅱ antibodies. The successful treatment
of this patient indicates the necessity of accurate management in TRALI
cases.
Case report with results
Our
hospital admitted a 52-year-old male patient suffering over a month from
head and neck skin ulceration and purulent secretions. The temperature
of his body was 36.8°C, with a pulse rate of 67 beats/min, a pressure
level of 120/76 mmHg in the blood, and a respiration capacity of 20
breaths/min. During the physical examination, clear bilateral lung
sounds were observed without extensive dry or wet rales. No abnormal
findings were observed on the electrocardiogram (ECG) and
echocardiography. Head and neck skin cultures demonstrated the presence
of gram‐positive Staphylococcus aureus (3+) and Serratia
marcescens (2+).
From day 2 to 6 after admission, the patient was provided four packed
red blood cells (PRBC) units with 2400 ml of frozen plasma (FP) due to
surgery, anemia, and severe wound exudation. No adverse effects occurred
during the transfusion, and arterial blood gas analysis indicated 99.8%
arterial oxygen saturation
(SpO2), 130 mmHg
partial pressure oxygen (PaO2), and 43.9 mmHg carbon
dioxide partial pressure (PaCO2).
On the seventh day of hospitalization, the patient suddenly developed
respiratory distress, dyspnea, and severe hypoxemia after receiving
approximately 100 ml of FP (SpO2 64.1%;
PaO2 33.8 mmHg; PaCO2 39.6 mmHg). The
plasma transfusion was immediately discontinued, and the patient was
treated with facemask oxygen at 60L/min. Additionally, he was
intravenously administered 5mg dexamethasone due to suspected allergic
transfusion reactions. However, the hypoxic symptoms did not improve.
Coarse breathing sounds could be heard in the bilateral lungs upon
auscultation, and a chest radiograph suggested bilateral pulmonary
infiltrates. A heart rate of 136 beats/min was observed through an
urgent echocardiogram, with the ventricle and atrium presenting a
regular silhouette. The patient was intubated, mechanically ventilated,
and subsequently transferred to the intensive care unit (ICU) because of
worsening conditions. Ventilator settings were adjusted to synchronous
intermittent mandatory ventilation (SIMV) mode using 10 cm
H2O positive end-expiratory pressure (PEEP) and a 90%
fraction of inspired oxygen (FiO2). After three days of
oxygen support, the patient’s condition gradually improved, and
PaO2 level became normal. He was transferred to the burn
and orthopedics department to treat the infected wound. FIGURE 1 depicts
the lung imaging.
We conducted high-resolution HLA genotyping to determine if TRALI was
developed. The HLA type of the
recipient was identified as HLA-A* 24:02, 30:01; HLA-B* 13:02, 35:03;
HLA-C* 06:02, 12:03; DRB1* 07:01, 07:01; DQB1* 02:02, 03:03; and DPB1*
04:01, 13:01. The recipient had received blood transfusions from a
female plasma donor. The specific antibodies HLA-DRB1* 07:01 (MFI 17322)
and HLA-DQB1*02:02 (MFI 1366-1475) could be detected upon testing in
donor plasma and considered responsible for TRALI
development.
This TRALI version, characterized by the two antibodies, was not
previously reported in China.
According to the symptoms and clinical course of the patient, this case
satisfies the TRALI Type I category of diagnostic
assessment.4 The case occurred within six hours of
blood transfusion; hypoxemia (SpO2 <90% on
room air); novel bilateral lung infiltrates could be observed on chest
radiography (Figure 1A and 1B); without any evidence of pulmonary
vascular overload or acute respiratory distress syndrome (ARDS) risk
factors.
Discussion
Most studies demonstrate that plasma donated by parous females is the
blood product commonly associated with TRALI. Several countries have
incorporated plasma from male donors to mitigate the risk of TRALI. The
blood donor, in this case, was identified as female. Still, her
fertility and transfusion history were unknown, preventing additional
clarification of her in vivo HLA antibody sources. She had donated blood
six times without any transfusion adverse events other than this. This
could be due to insufficient TRALI awareness among clinicians and an
imperfect reporting system for such adverse reactions in China. A study
evaluating the clinical outcomes of TRALI in a Chinese population
revealed that 34.5% (20 out of 58) led to death. Moreover, logistic
regression analysis indicated that misdiagnosis affected patient
outcomes.5 The primary factor behind the successful
recovery of this case could be attributed to the timely identification
and provision of effective oxygen therapy by the clinician coupled with
supportive care. Therefore,
improving TRALI awareness among clinicians would ensure the well-being
of patients. The diagnosis and management of TRALI still need to be
fully developed in China. Consequently, several proactive measures
should be implemented to minimize the occurrence and mortality rates
associated with TRALI.