(P-TS-64) Looking At TRALI Transfusion Reactions In Reverse: A Case Study

Transfusion-related acute lung injury (TRALI) is a transfusion reaction that stems from the antibody/antigen interactions between anti-human leukocyte antigen (HLA) or anti-human neutrophil antigen (HNA) of the recipient and donor blood products. Historically, the most common blood products that cause TRALI reactions are products containing larger volumes of plasma, typically from previously pregnant female donors. TRALI typically is thought to occur when the donor of the blood product has antibodies to HLAs or HNAs. However, rare other causes have been described and this case study will present an unusual cause of TRALI.

Study

Design/Methods:

A 60 year old female with a history of AML, presented with neutropenic fever and pneumonia. Due to thrombocytopenia, the patient was transfused with one unit of apheresis platelets. Roughly 15 minutes after the completion of the transfusion the patient exhibited symptoms of a transfusion reaction which included chills, fever, dyspnea, cough and crackles on auscultation. Chest x-ray showed bilateral infiltrates. She was subsequently transferred to the ICU and intubated. Approximately 48 hours after the platelet transfusion, a transfusion reaction was reported. Clerical check could not be completed since the platelet bag had been discarded, however, based on the clinical presentation, TRALI as was transfusion associated circulatory overload (TACO) was suspected. An adverse event report along with patient blood samples were sent to the blood supplier for a TRALI investigation.

Results/Findings:

The apheresis platelet donor was male without history of transfusion. The donor antibody screens were negative for HLA Class I, II and HNA antibodies. Patient testing demonstrated class I and II HLA antibodies. The platelet donor was then typed for class I HLA antigens and found to be positive for A3, A68, and B8 which the patient had HLA antibodies to. Given the clinical picture and the matches between the donor’s antigens and the recipient’s antibodies, this transfusion reaction was classified as reverse TRALI. Of note, this patient has received several transfusions since without issue or adverse events reported.

Conclusions:

Both TRALI and reverse TRALI are ultimately clinical diagnoses and can be difficult to recognize. Laboratory testing can help identify and support these diagnosis. However, clinical teams must be vigilant when patient’s exhibit signs and symptoms of TRALI or reverse TRALI in response to blood products so that proper notification and testing can be conducted.