대한흉부영상의학회 Weekly Chest Cases

Case No : 984 Date 2016-09-05

Courtesy of Kye Ho Lee, MD / Dankook University Hospital
Age/Sex 67 / M
Chief ComplaintAnemia. Sudden onset of dyspnea and decreased oxygen saturation level.

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Initial

Diagnosis With Brief Discussion

Diagnosis: Transfusion related acute lung injury
Radiologic Findings: Fig 1. Chest radiograph performed before and after transfusion. (A) Chest radiography before transfusion shows clear lungs without abnormal opacities. (B) Chest radiography performed 5 hours after initiation of transfusion newly shows perihilar ground glass opacities in both lungs with normal cardiac silhouette.
Fig 2. Lung window setting of chest CT scan performed 2 hours after the onset of dyspnea. Axial (A, B and C) and coronal reconstructed (D and E) images show confluent geographic consolidations and ground-glass opacities in both lungs with perihilar predominance. Associated mild septal thickening is also noted.
Transthoracic echocardiography was performed and showed normal size of cardiac chambers with good LV systolic function. (LVEF : 75%)
Because the onset of dyspnea was sudden, bilateral pulmonary infiltrations appeared immediately after transfusion, and the patient had good cardiac function, cardiogenic pulmonary edema was excluded and transfusion-related acute lung injury was clinically suspected.
The patient was admitted for intensive respiratory care. Bronchoalveolar lavage fluid obtained on the next day showed no growth of abnormal organisms. Patient was treated with oxygen supplement and empirical antibiotics, but the symptoms aggravated and the patient expired 14 days after admission.
Brief Review: Transfusion-related acute lung injury (TRALI), defined as the onset of respiratory distress after blood transfusion, is a potentially life-threatening complication of blood transfusion therapy. TRALI is a clinical diagnosis of exclusion, and diagnosis of this syndrome is established using clinical and radiological parameters. Suspected TRALI is defined as acute lung injury within 6 hours of transfusion in the absence of other risk factors, such as sepsis or lung contusion.
TRALI is known to occur with the transfusion of any cell-containing blood product, cryoprecipitates, intravenous immunoglobulins, and as little as 50 ml of plasma-rich blood product. Pathogenesis is not fully understood, but a two-hit hypothesis has been proposed. The first hit is underlying patient factors, such as sepsis or recent surgery, resulting in adherence of primed neutrophils to the pulmonary endothelium. The second hit is mediators in blood transfusion that activate the endothelial cells and pulmonary neutrophils, resulting in capillary leakage and subsequent pulmonary edema.
Radiographic findings of TRALI are nonspecific and are generally worse than the physical exam findings. Chest radiograph shows interstitial opacities, patchy alveolar opacities, and diffuse lung haziness. Septal lines and pleural effusions occasionally develop. Findings are usually indistinguishable from those of hydrostatic pulmonary edema. Lung opacities usually clear within 96 hours in 80% of patients diagnosed with TRALI. Chest CT shows parenchymal consolidations and air bronchograms, with or without ground-glass opacities in heterogeneous distribution. These findings can be seen in coexistence with normally aerated lung.
Management of TRALI is supportive, with most requiring supplementary oxygen, and mechanical ventilation is unavoidable in 70-90% of cases. TRALI is regarded as part of acute lung injury (ALI) or acute respiratory distress syndrome (ARDS), and diuretics and restrictive fluid strategy may be beneficial. TRALI generally has a good prognosis and mortality is considered to be roughly 5-10%.
References: 1. Vlaar AP, Juffermans NP. Transfusion-related acute lung injury: a clinical review. Lancet 2013; 382(9896): 984-94.
2. Carcano C. et al. Radiographic manifestation of transfusion-related acute lung injury. Clin imaging 2013; 37(6): 1020-3
Please refer to: Case 447
Keywords: Lung, Iatrogenic lung disease, Drug complication,

No. of Applicants : 87

▶ Correct Answer : 23/87, 26.4%

- The University of Tokyo Hospital , Japan Akifumi Hagiwara
- Samsung Medical Center , Korea (South) Boda Nam
- Ichinomiya Nishi Hospital , Japan Takao Kiguchi
- Ajou University Hospital , Korea (South) Seulgi You
- , Korea (South)
- Korea University Guro Hospital , Korea (South) Jeong Woo Kim
- GHICL , France manuel toledano
- Seoul national university hospital , Korea (South) Kumju Chae
- Fortis hospital , Mohali , India Shaleen Rana
- privato , Italy genchi enzo
- Ajou university hospital , Korea (South) Pae Sun Suh
- Kyungpook national university , Korea (South) Chungeun Lim
- Kanto Rosai Hospital , Japan Taku Tajima
- Ajou University Hospital , Korea (South) Young Keun Sur
- Diagnose.me (BV) / Royal Perth Hospital , Australia Yuranga Weerakkody
- , Korea (South) BAEK YOOLIM
- Ajou university hospital , Korea (South)
- Private sector , Greece Vasilios Tzilas
- Ajou university hospital , Korea (South) DONGHYUN LEE
- Ajou University Hospital , Korea (South) Youngjin Yoo
- CHU Poitiers , France CHAN paul
- The University of Tokyo Hospital , Japan Kaoru Sumida
- Medicheck health care , Korea (South) Chae Lim

▶ Correct Answer as Differential Diagnosis : 9/87, 10.3%

- Seoul National University Hospital , Korea (South) Hyoung-In Choi
- SNUH , Korea (South) TAE HYUNG KIM
- SNUH , Korea (South) Juil Park
- Seoul National University Hospital , Korea (South) Sunkyung Jeon
- McGill University Health Center , Canada Alexandre Semionov
- Department of Radiology, Seoul National University Bundang Hospital , Korea (South) Sung Hyun Yoon
- Asan Medical Center , Korea (South) Hyung Jung Koo
- Ajou University Hospital , Korea (South) Taeyang Ha
- Centre Imagerie de Fribourg , Switzerland Benoit RIZK

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 984 Date 2016-09-05

Discussion

No. of Applicants : 87