대한흉부영상의학회 Weekly Chest Cases

Case No : 447 Date 2006-05-22

Courtesy of Ok Hee Woo, MD, Hwan-Seok Yong, MD, Eun-Young Kang, MD. / Korea University Guro Hospital, Seoul, Korea
Age/Sex 70 / M
Chief ComplaintSep 2005: Diagnosed as adenocarcinoma in RUL (T4N2M0) Jan 13 2006: Completion of 6th cycle chemotherapy Jan 20 2006: Neutropenic state Jan 22 2006: Transfusion of packed RBC Jan 23 2006: Chest discomfort and dyspnea developed.

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Diagnosis With Brief Discussion

Diagnosis: Transfusion-Related Acute Lung Injury (TRALI)
Radiologic Findings: Chest radiograph on Jan. 20, 2006 shows the malignant mass in RUL and pleural effusion in right hemithorax. Chest radiograph on Jan. 23, 2006 within the first 8 hr after transfusion shows new opacities including bilateral ground glass opacities with a normal cardiac silhouette. Chest CT scan shows geographic ground glass opacities in both lungs with sparing previous constrictive bronchiolitis areas. A clinical diagnosis of a non-cardiogenic pulmonary edema was made, thus we excluded other causes such as sepsis, volume overload, cardiogenic pulmonary edema and drug-induced lung injury. On the basis of clinical signs and symptoms, the diagnosis of transfusion-related acute lung injury (TRALI) was suggested.

The patient was given supportive management, with a high concentration of oxygen in combination with bronchodilators. Clinical improvement occurred 12 hours later and the chest film returned to normal within 6 days (see below).
Brief Review: Transfusion-related acute lung injury (TRALI) is an underreported complication of transfusion therapy, and it is the third most common cause of transfusion-associated death. TRALI is defined as noncardiogenic pulmonary edema temporally related to transfusion therapy.

The pathogenesis of TRALI may be explained by a "two-hit" hypothesis, with the first "hit" being a predisposing inflammatory condition commonly present in the operating room or ICU. The second hit may involve the passive transfer of neutrophil or HLA antibodies from the donor or the transfusion of biologically active lipids from older, cellular blood products.

The diagnosis of TRALI relies on excluding other diagnoses such as sepsis, volume overload, and cardiogenic pulmonary edema. Supportive diagnostic evidence includes identifying neutrophil or human leukocyte antigen (HLA) antibodies in the donor or recipient plasma. All plasma-containing blood products have been implicated in TRALI, with the majority of cases linked to whole blood, packed RBCs, platelets, and fresh-frozen plasma.

Radiographic finding shows diffuse, fluffy infiltrates consistent with pulmonary edema, which may be patchy in the first few hours, with progression of the alveolar and interstitial infiltrates such that the entire lung is obscured. Resolution often occurs rapidly, even when initial hypoxemia is severe. Most patients can be extubated within 48 hours, and chest radiographs typically return to normal in 4 days, although hypoxemia and pulmonary infiltrates persist up to 7 days in a minority of patients.

The first step in the treatment of TRALI is to make the correct diagnosis. Treating TRALI like cardiogenic pulmonary edema or volume overload may lead to adverse outcomes. Treatment is supportive, with a prognosis substantially better than most causes of clinical acute lung injury.
References: 1. Looney MR, Gropper MA, Matthay MA. Transfusion-related acute lung injury. Chest 2004;126:249-258.

2. Tsalis K, Ganidou M, Blouhos K, Vasiliadis K, Betsis D. Transfusion-related acute lung injury: a life-threatening transfusion reaction. Med Sci Monit 2005;11:CS19-22
Keywords: Lung, Iatrogenic lung disease, Interstitial lung disease, ILD,

No. of Applicants : 43

▶ Correct Answer : 18/43, 41.9%

- Doctors Hospital, Nassau, Bahamas N.B.S.Mani
- Inje University Ilsan Paik Hospital, Korea Bae Geun Oh
- Maimonides Medical Center; Brooklyn, New York, USA Naomi Twersky
- National Taiwan University Hospital, Taiwan Yu-Feng Wei
- Inje University Ilsan Paik Hospital, Korea Seung Tae Lee
- EKH, Berlin, Germany Michael Weber
- Hospital Sotiria, Athens, Greece Tzilas Vasilios
- National Taiwan University Hospital, Taiwan Hsu Chi-Kuei
- MGM Medical College, Indore, India Sonali Jain
- Homs National Hospital, Homs, Syria Rami Abou Zalaf
- Mackay Memorial Hospital, Taiwan Kuang-Hua Cheng
- Radiologie Guiton, La Rochelle, France Denis Chabassiere
- Yonsei University Shinchon Severance Hospital, Korea Hye-Jeong Lee
- Yonsei University Shinchon Severance Hospital, Korea Yong Eun Chung
- Max Hospital, New Delhi, India Vickrant Malhotra
- Diskapi Yildirim Beyazit Hospital, Ankara, Turkey Meric Tuzun
- Samsung Medical Center, Seoul, Korea Ha Young Kim
- Hangang Sacred Heart Hospital, Korea Eil Seong Lee

▶ Correct Answer as Differential Diagnosis : 2/43, 4.7%

- Annemasse, Polyclinique de Savoie, France Gay-Depassier Philippe
- China Medical University Hospital,Taiwan Jun-Jun Yeh

▶ Semi-Correct Answer : 7/43, 16.3%

- Nirman Hi-tech Diagnostic Center, Mumbai, India Minal Seth
- Ondokuz Mayis University, Samsun, Turkey Cetin Celenk
- Yonsei University Shinchon Severance Hospital, Korea Eun Hye Yoo
- Clinic 1, Russia Lepikhina Dasha
- Sam Anyang Hospital, Korea Jae Seung Seo
- Cabinet de Radiologie Guiton, La Rochelle, France Jean-Luc Bigot
- Pusan National University Hospital, Korea Kun-Il Kim

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 447 Date 2006-05-22

Discussion

No. of Applicants : 43