A 65-year-old man comes to the emergency department (ED) due to recurrent hematemesis. Over the past few months, he has had melena, exertional dyspnea, dizziness, and fatigue. The patient takes ibuprofen for knee osteoarthritis. He has no other medical conditions. Hemoglobin level on arrival to the ED is 6 g/dL. The patient is given 2 L of intravenous normal saline and 2 units of packed red blood cells. During transfusion of the second unit of blood, he develops significant dyspnea. He denies chest pain. Temperature is 36.9 C (98.4 F), blood pressure is 90/70 mm Hg, pulse is 120/min, and respirations are 30/min. Oxygen saturation is 80% on room air. The patient is in marked respiratory distress and uses accessory muscles for breathing. Cardiopulmonary examination shows bilateral crackles, no stridor, normal heart sounds, and no S3 or murmur. The abdomen is mildly tender in the epigastrium. The extremities are cool to touch, with no edema, and there is no rash. A chest radiograph reveals bilateral pulmonary infiltrates, a normal-sized heart, and no pleural effusion. Plasma brain natriuretic peptide concentration is within the reference range. Which of the following is the most likely diagnosis?

Question

A 65-year-old man comes to the emergency department (ED) due to recurrent hematemesis.  Over the past few months, he has had melena, exertional dyspnea, dizziness, and fatigue.  The patient takes ibuprofen for knee osteoarthritis.  He has no other medical conditions.  Hemoglobin level on arrival to the ED is 6 g/dL.  The patient is given 2 L of intravenous normal saline and 2 units of packed red blood cells.  During transfusion of the second unit of blood, he develops significant dyspnea.  He denies chest pain.  Temperature is 36.9 C (98.4 F), blood pressure is 90/70 mm Hg, pulse is 120/min, and respirations are 30/min.  Oxygen saturation is 80% on room air.  The patient is in marked respiratory distress and uses accessory muscles for breathing.  Cardiopulmonary examination shows bilateral crackles, no stridor, normal heart sounds, and no S3 or murmur.  The abdomen is mildly tender in the epigastrium.  The extremities are cool to touch, with no edema, and there is no rash.  A chest radiograph reveals bilateral pulmonary infiltrates, a normal-sized heart, and no pleural effusion.  Plasma brain natriuretic peptide concentration is within the reference range.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d202_ab9c_bc81_9d91f42d313a_MD0003_00 This patient developed acute hypoxemic respiratory failure (hypoxia, tachypnea) with bilateral pulmonary infiltrates during blood transfusion. His normal brain natriuretic peptide concentration, normal cardiac size, and lack of jugular venous distension make acute cardiogenic pulmonary edema from transfusion-associated circulatory overload unlikely (Choice E). Therefore, the most likely diagnosis is transfusion-related acute lung injury (TRALI). TRALI is a rare but life-threatening complication of blood product transfusion marked by the massive release of cytokines, reactive oxygen species, and other inflammatory mediators from neutrophils in the pulmonary vasculature in response to transfused blood components. Manifestations begin within a few hours of transfusion initiation and include acute, inflammatory pulmonary edema with hypoxia, tachypnea, and bilateral pulmonary infiltrates. Fever, tachycardia, and hypotension also commonly occur. Treatment includes immediate cessation of the transfusion and ventilatory support. Some patients recover within 24-48 hours, but up to 50% die. (Choice A) Anaphylactic transfusion reaction most often occurs in those with IgA deficiency due to the reaction of anti-IgA antibodies with transfused blood. Respiratory distress and hypotension are common, but patients also have hives, wheeziness, stridor, and/or angioedema. This patient's lack of rash, stridor, or wheeziness makes anaphylaxis unlikely. (Choice B) Aspiration pneumonia is most common in those who have episodes of diminished consciousness (eg, alcohol/drug abuse) or dysphagia. Patients often develop acute hypoxemic respiratory failure, dyspnea, low-grade fever, and infiltrates in the dependent portions of the lung. However, the onset of symptoms during blood transfusion (and lack of risk factors for aspiration) makes TRALI far more likely than aspiration pneumonia. (Choice D) Transfusion-transmitted bacterial infection is associated with high fever, rigors, tachycardia, and hypotension. This patient's lack of fever and acute pulmonary symptoms make TRALI far more likely. Educational objective: Transfusion-related acute lung injury typically occurs within minutes or a few hours of blood product transfusion. It manifests with acute hypoxemic respiratory failure and bilateral pulmonary infiltrates. In contrast to patients with transfusion-associated circulatory overload, those with TRALI typically have normal brain natriuretic peptide and no jugular venous distension.

A 65-Year-Old Man Comes to the Emergency Department (ED) Due