A 48-year-old man develops fever, dyspnea, and bilateral pulmonary infiltrates after a transfusion during surgery. Which item is inconsistent with a diagnosis of transfusion-related acute lung injury (TRALI)?

A 48-year-old man develops fever, dyspnea, and bilateral pulmonary infiltrates after a transfusion during surgery. Which item is inconsistent with a diagnosis of transfusion-related acute lung injury (TRALI)?

• A. Fever
• B. Arterial to alveolar oxygen gradient of 25 mm Hg
• C. Acute rise in neutrophil count after onset of symptoms
• D. Bilateral pulmonary infiltrates

Answer: (C)

TRALI is an acute, noncardiogenic pulmonary edema that occurs within about 6 hours of a transfusion. The lungs become leaky because donor antibodies or donor-primed leukocytes activate recipient neutrophils in the pulmonary microvasculature, leading to fluid leakage into the air spaces. Clinically, you see fever can be present, dyspnea with hypoxemia, and bilateral infiltrates on chest imaging, all without evidence of circulatory overload or left atrial hypertension. The arterial to alveolar oxygen gradient is widened because gas exchange is impaired by the edema. An acute rise in circulating neutrophil count after symptoms begin isn’t part of TRALI’s typical pattern. Neutrophils tend to be recruited into the lungs (and may even be depleted from the blood), so a sudden peripheral neutrophilia is not characteristic of TRALI. That’s why this statement is inconsistent with TRALI, making it the best choice.

TRALI is an acute, noncardiogenic pulmonary edema that occurs within about 6 hours of a transfusion. The lungs become leaky because donor antibodies or donor-primed leukocytes activate recipient neutrophils in the pulmonary microvasculature, leading to fluid leakage into the air spaces. Clinically, you see fever can be present, dyspnea with hypoxemia, and bilateral infiltrates on chest imaging, all without evidence of circulatory overload or left atrial hypertension. The arterial to alveolar oxygen gradient is widened because gas exchange is impaired by the edema.

An acute rise in circulating neutrophil count after symptoms begin isn’t part of TRALI’s typical pattern. Neutrophils tend to be recruited into the lungs (and may even be depleted from the blood), so a sudden peripheral neutrophilia is not characteristic of TRALI. That’s why this statement is inconsistent with TRALI, making it the best choice.