Transfusion-related acute lung injury due to granulocyte-agglutinating antibody in a patient with paroxysmal nocturnal hemoglobinuria

What is the role of complement in bystander hemolysis? Old concept, new insights

INTRODUCTION

Bystander hemolysis occurs when antigen-negative red blood cells (RBCs) are lysed by the complement system. Many clinical entities including passenger lymphocyte syndrome, hyperhemolysis following blood transfusion, and paroxysmal nocturnal hemoglobinuria are complicated by bystander hemolysis.

AREAS COVERED

The review provides data about the role of the complement system in the pathogenesis of bystander hemolysis. Moreover, future perspectives on the understanding and management of this syndrome are described.

EXPERT OPINION

Complement system can be activated via classical, alternative, and lectin pathways. Classical pathway activation is mediated by antigen-antibody (autoantibodies and alloantibodies against autologous RBCs, infectious agents) complexes. Alternative pathway initiation is triggered by heme, RBC microvesicles, and endothelial injury that is a result of intravascular hemolysis. Thus, C5b is formed, binds with C6-C9 compomers, and MAC (C5b-9) is formulated in bystander RBCs membranes, leading to cell lysis. Intravascular hemolysis, results in activation of the alternative pathway, establishing a vicious cycle between complement activation and bystander hemolysis. C5 inhibitors have been used effectively in patients with hyperhemolysis syndrome and other entities characterized by bystander hemolysis.

A threshold model for the susceptibility to transfusion-related acute lung injury

Transfusion-related acute lung injury (TRALI) is a serious, often life-threatening pulmonary transfusion reaction characterized by non-cardiogenic lung oedema, hypoxemia and respiratory distress in temporal association with blood transfusion. The critical mechanism in TRALI is the sudden increase in permeability of the pulmonary endothelium and the subsequent, often extensive shift of fluid into the alveolae. The rapid clinical recovery seen in most patients makes it likely that this is a temporary phenomenon. Reactive oxygen species released by neutrophils or other cells are attractive candidate mediators of this process. There is experimental and clinical evidence that several pathways can induce barrier breakdown in TRALI, a concept known as the threshold model of TRALI. Surprisingly, neutrophils may not always be required. Other cells may play a role as multipliers or attenuators of TRALI, depending on recipient-related and transfusion-related factors involved. This review will summarize recent findings on pathophysiology, with a focus on newly discovered or disenchanted recipient-related and transfusion-related risk factors for TRALI and will present the threshold model of TRALI as a unifying concept on how TRALI develops.

Transfusion-related Acute Lung Injury: Report of Two Cases

Transfusion-related acute lung injury (TRALI) is a severe life-threatening complication of blood transfusion, characterized by acute lung injury developing within 2–6 h of transfusion. However, TRALI is difficult to diagnose, and the initial report or suspicion of TRALI depends on close collaboration between clinical departments and transfusion centres. A total of 17 adverse post-transfusion reactions were reported to the Blood Centre of the University Hospital Ostrava as suspected TRALI between 2005 and 2010. We report two cases of serious TRALI with different pathogenetic mechanisms.

The practice of reporting transfusion-related acute lung injury: a national survey among clinical and preclinical disciplines

BACKGROUND

Transfusion-related acute lung injury (TRALI) is hypothesized to be a "two-hit" entity, in which an inflammatory condition (e.g., sepsis) predisposes to TRALI. TRALI is a clinical diagnosis. Disciplines involved in managing TRALI may differ in decision-making on the reporting of TRALI.

STUDY DESIGN AND METHODS

A survey was conducted among critical care physicians, hematologists, hemovigilance workers, and transfusion medicine physicians, using case vignettes and a questionnaire. The vignettes varied in patient- and blood product-related factors that may influence the decision to report a TRALI case. Multiple linear regression analysis was performed. A positive beta-coefficient is in favor of reporting.

RESULTS

Ninety-two questionnaires were returned (response rate, 68%). For all disciplines, preferences in favor of reporting TRALI were onset of symptoms within 1 hour (beta = 0.4), after transfusion of a single unit of FFP (beta = 0.5), and in the absence of acute lung injury before transfusion (beta = 1.3). An admission diagnosis of sepsis was a negative preference (beta = -0.3). Massive transfusion (6 RBC plus 4 FFP units) was a negative preference for transfusion medicine physicians (beta = -0.3), but a positive preference for the other disciplines. The questionnaire revealed that massive transfusion and the age of blood products were considered relatively more important reasons to report TRALI by critical care physicians compared to the other disciplines (p < 0.05).

CONCLUSION

A pretransfusion inflammatory condition is a reason to withhold from reporting of a suspected TRALI case. Disciplines involved in managing TRALI differ in decision-making of reporting TRALI, which may contribute to variance in incidence.

Pulmonary transfusion reactions

BACKGROUND

In recent years, pulmonary transfusion reactions have gained increasing importance as serious adverse transfusion events.

METHODS

Review of the literature.

RESULTS

Pulmonary transfusion reactions are not extremely rare and, according to hemovigilance data, important causes of transfusion-induced major morbidity and death. They can be classified as primary with predominant pulmonary injury and secondary as part of another transfusion reaction. Primary reactions include transfusion-related acute lung injury (TRALI), transfusion-associated circulatory overload (TACO) and transfusion-associated dyspnea (TAD). Secondary pulmonary reactions are often observed in the wake of hemolytic transfusion reactions, hypotensive/anaphylactic reactions, and transfusion-transmitted bacterial infections.

CONCLUSION

Knowledge and careful management of cases of pulmonary transfusion reactions are essential for correct reporting to blood services and hemovigilance systems. Careful differentiation between TRALI and TACO is important for taking adequate preventive measures.

How free of residual cells and cell antigens is human blood plasma? A comparison of different production methods of human blood plasma and the risk of the products for patients

The aim of this investigation was to compare 11 different production procedures for human blood plasma, using preparative apheresis and whole blood. We intended to determine the plasma quality in regard to the number of residual cells or cell fragments. Cells were analysed using the Cell-Dyn 4000 blood cell counter and cell fragments were detected by an immunoassay. Antigenic structure could be detected in clearly different quantities corresponding to the separation technique used. Methods which separated blood components only with centrifugation produced plasma with more detectable cellular material than plasma produced with additional membrane filtration. No remaining antigenic fragments were detected when an additional plasma filter was used.

Transfusion-related acute lung injury and leucocyte-reacting antibodies

BACKGROUND AND OBJECTIVES

Transfusion-related acute lung injury (TRALI) is underdiagnosed and underreported. This is why we present cases suspected for TRALI, in which leucocyte antibodies were examined.

MATERIAL AND METHODS

We analysed 44 patients with respiratory insufficiency, related to transfusion, who met criteria of acute lung injury (ALI). Lymphocyte and granulocyte antibodies were examined in donors and patients by six methods.

RESULTS

Based on recent trends, we divided patients into two groups: TRALI (without risk factors for ALI) and possible TRALI (with probable risk factors). The incidence of antibodies was 68.2%, the majority were human leucocyte antigen (HLA) class I and/or II, the minority were non-specific granulocyte antibodies; half of all detected antibodies, however, reacted with granulocytes. Antibodies were found in 17 donors (more often in TRALI than in possible TRALI) and in 19 patients (in four - suspected to be of the donor origin, which would diminish the number of antibodies to 15). In seven available cases, we observed cognate antigen and/or positive cross-match. In the majority of patients, TRALI occurred after transfusion of red cells, in 56.2%- stored above 14 days; all the units were non-leucoreduced. Lookback in two donors showed that transfusions in 20 patients did not result in reported TRALI, even in the patient with cognate antigen.

CONCLUSIONS

Our clinical observations suggest that to distinguish between TRALI and possible TRALI is difficult and the results are equivocal - it is worth considering whether it can be omitted. We have confirmed that antibodies are involved in TRALI, although their role is very complex. The role of stored red blood cells in the development of TRALI requires further observations in comparison with a control group of patients without TRALI.

Detection of anti-CD32 alloantibody in donor plasma implicated in development of transfusion-related acute lung injury

Transfusion-related acute lung injury (TRALI) occasionally causes serious symptoms that may be fatal to recipients. Polymorphonuclear neutrophils (PMNs) and alloantibodies specific to PMN cell surface antigens are suspected to cause TRALI. The aim of this study is to establish a sensitive and stable procedure of detecting alloantibodies not only in donor blood, but also in recipient's plasma. We have introduced a new method of detecting alloantibodies based on double-determinant enzyme-linked immunosorbent assay (DD-ELISA) and a monoclonal antibody-immobilized granulocyte antigen (MAIGA) test (arbitrarily designated as modified DD-ELISA). We verified the specificity of alloantibodies against PMN cell surface antigens in plasma samples from three normal healthy donors of blood that induced respiratory distress in recipients after a blood transfusion. Anti-CD32 (Fc gamma RIII) alloantibodies were detected in all the plasma samples using two different clones of the monoclonal anti-CD32 antibody. The specificities of these plasma samples could not be identified by the granulocyte immunofluorescence test (GIFT) using typed test cells. Except for the anti-CD32 alloantibodies, one plasma sample was proved to have the anti-HNA-1a alloantibodies. In another plasma sample, the anti-HNA-2a alloantibodies were detected. By modified DD-ELISA, we could clearly specify the presence of alloantibodies in the three plasma samples. Our results also suggest that the anti-CD32 alloantibodies can be generated in vivo and may play some roles in the development of TRALI.

Transfusion-Related Acute Lung Injury (TRALI): Current Clinical and Pathophysiologic Considerations

Transfusion-related acute lung injury (TRALI) is a rare transfusion reaction presenting as respiratory distress during or after transfusion of blood products. TRALI varies in severity, and mortality is not uncommon. TRALI reactions have equal gender distributions and can occur in all age groups. All blood products, except albumin, have been implicated in TRALI reactions. TRALI presents as acute respiratory compromise occurring in temporal proximity to a transfusion of a blood product. Other causes of acute lung injury should be excluded in order to definitively diagnose TRALI. Clinically and pathologically, TRALI mimics acute respiratory distress syndrome (ARDS), with neutrophil-derived inflammatory chemokines and cytokines believed to be involved in the pathogenesis of both entities. Anti-HLA and anti-neutrophil antibodies have been implicated in some cases of TRALI. Treatment for TRALI is supportive; prevention is important. It is suspected that TRALI is both underdiagnosed and underreported. One of the difficulties in the evaluation of potential TRALI reactions is, until recently, the lack of diagnostic criteria. A group of transfusion medicine experts, the American-European Consensus Conference (AECC), recently met and developed diagnostic criteria of TRALI, as well as recommendations for management of donors to prevent future TRALI reactions. In light of the AECC consensus recommendations, we report an incident of TRALI in an oncology patient as an example of the potential severity of the lung disease and the clinical and laboratory evaluation of the patient. We also review the literature on this important complication of blood transfusion that internists may encounter.

Mechanisms of transfusion-related acute lung injury (TRALI): anti-leukocyte antibodies

There is abundant evidence that leukocyte antibodies in blood donor products are somehow involved in transfusion-related acute lung injury (TRALI). Human leukocyte antigen (HLA) class I, HLA class II, and neutrophil-specific antibodies in the plasma of both blood donors and recipients have been implicated in the pathogenesis of TRALI. The case for a relationship between leukocyte antibodies and TRALI is more compelling if concordance between the antigen specificity of the leukocyte antibodies in the donor plasma and the corresponding antigen on the cells of the affected recipient is demonstrated. Such antibody-antigen concordance can be investigated by typing the recipient for the cognate leukocyte antigens or by cross-matching the donor plasma against the recipient's leukocytes. Two proposed pathophysiologic mechanisms for TRALI have received the most attention: the antibody hypothesis and the two-event hypothesis. The final common pathway in all of the proposed pathogenic mechanisms of TRALI is increased pulmonary capillary permeability, which results in movement of plasma into the alveolar space causing pulmonary edema. A typical TRALI serologic workup consists of tests for HLA class I and II and neutrophil-specific antibodies. The use of flow cytometry and HLA-coated microbeads is recommended for detection of HLA antibodies in plasma of implicated blood donors and a combination of the granulocyte agglutination test and granulocyte immunofluorescence test for detection of neutrophil-specific antibodies. Genotyping for class I and II HLA and for a limited number of neutrophil antigens may also be helpful in establishing antibody-antigen concordance.

Transfusion-related acute lung injury

PURPOSE OF REVIEW

Transfusion-related acute lung injury is an uncommon complication of blood transfusion typically manifested by shortness of breath, fever, and hypotension. Transfusion-related acute lung injury is an important cause of transfusion-related morbidity and mortality.

RECENT FINDINGS

Much about the pathogenesis, treatment, and prevention of transfusion-related acute lung injury is poorly understood or is controversial. There is increasing recognition that transfusion-related acute lung injury is an important clinical syndrome, causing most transfusion-related deaths.

SUMMARY

In this report, what is known about transfusion-related acute lung injury is summarized with particular emphasis on recent studies. Some of the areas in which knowledge and/or consensus are currently lacking are identified.

Transfusion-related acute lung injury (TRALI): a serious adverse event of blood transfusion

BACKGROUND AND OBJECTIVES

Analyses of fatal transfusion reactions in the UK and USA have shown that transfusion-related acute lung injury (TRALI) is among the most common causes of fatal transfusion reactions.

MATERIAL AND METHODS

Review of the literature was used to analyse TRALI.

RESULTS

TRALI is characterized by acute respiratory distress and non-cardiogenic lung oedema developing during, or within 6 h of, transfusion. In atypical cases, TRALI can become symptomatic much later. TRALI must be carefully differentiated from transfusion-associated circulatory overload. In its fulminant presentation, TRALI can be clinically indistinguishable from acute respiratory distress syndrome occurring as a result of other causes. The severity of TRALI depends upon the susceptibility of the patient to develop a more clinically significant reaction as a result of an underlying disease process, and upon the nature of triggers in the transfused blood components, including granulocyte-binding alloantibodies (immune TRALI) or neutrophil-priming substances such as biologically active lipids (non-immune TRALI). Immune TRALI, which occurs mainly after the transfusion of fresh-frozen plasma and platelet concentrates, is a rare event (about one incidence per 5000 transfusions) but frequently ( approximately 70%) requires mechanical ventilation (severe TRALI) and is not uncommonly fatal (6-9% of cases). Non-immune TRALI, which occurs mainly after the transfusion of stored platelet and erythrocyte concentrates, seems to be characterized by a more benign clinical course, with oxygen support sufficient as a form of therapy in most cases, and a lower mortality than immune TRALI.

CONCLUSIONS

By virtue of its morbidity and mortality, TRALI has become one of the most serious current complications of transfusion. To prevent further antibody-mediated cases, the evaluation of TRALI should include leucocyte antibody testing of implicated donors. However, further studies are necessary for the prevention of this serious transfusion complication.

Transfusion related acute lung injury: a pediatric perspective

Transfusion-related acute lung injury (TRALI) is the leading cause of transfusion-associated mortality. TRALI occurs in children and adults, but the syndrome has not been reviewed from a pediatric perspective. We reviewed the literature on TRALI from a pediatric perspective. TRALI has been documented in pediatric patients, especially in the setting of hematologic malignancy. Additional TRALI cases have been reported in pediatric patients with a variety of diagnoses. TRALI is likely to be much more common than previously appreciated in the pediatric patient population. TRALI should be considered in the differential diagnosis of all pediatric patients who develop new acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) during or within six hours of a blood product transfusion. When a case of TRALI is suspected, a transfusion reaction report to the blood bank is important to initiate the investigation and identify the implicated donor.

Syndrome de détresse respiratoire aiguë post-transfusionnel : une pathologie méconnue

Transfusion related acute lung injury (TRALI) is a rare but potentially severe complication of blood transfusion, manifested by pulmonary oedema, fever and hypotension. The signs and symptoms are often attributed to other clinical aspects of a patient's condition, and therefore, TRALI may go unrecognised. It has been estimated to be the third cause of transfusion related mortality, so it should be better diagnosed. Cases are related to multiple blood units, such as white blood cells, red blood cells, fresh frozen plasma, platelets or intravenous immunoglobulins. Physiopathology of TRALI is poorly understood, and still controversial. It is often due to an immunological conflict between transfused plasma antibodies and recipients' blood cells. These antibodies are either HLA (class I or II) or granulocyte-specific. They appear to act as mediators, which result in granulocytes aggregation, activation and micro vascular pulmonary injury. Lipids or cytokines in blood units are also involved as TRALI priming agents. Diagnosis is based on antibody screening in blood components and on specific-antigen detection in the recipient. The screening of anti-HLA or anti-granulocytes is recommended as part of prevention for female donors who had been pregnant. Preventative measures should also include leucoreduction and measures to decrease the amount of priming agents in blood components. In this article, we summarise what is known about TRALI, and we focus attention on unanswered questions and controversial issues related to TRALI.

Transfusion-related acute lung injury

Transfusion-related acute lung injury (TRALI) is an uncommon complication of allogeneic blood transfusion manifested typically by shortness of breath, fever, and hypotension. It has been estimated to occur in 0.04% to 0.16% per patient transfused. TRALI has been identified as an important cause of transfusion-related morbidity and mortality. Despite the increasing recognition that TRALI represents an important clinical syndrome, much about the pathogenesis, treatment, and prevention of TRALI is poorly understood or is controversial. In this report, what is known about TRALI is summarized and some of the areas in which knowledge and/or consensus are currently lacking are identified.

Transfusion-related acute lung injury during plasma exchange: Suspecting the unsuspected

Transfusion-related acute lung injury (TRALI) has been implicated with use of almost all types of blood products that contain variable amounts of plasma. Even though the reported incidence of TRALI is rare, its overall occurrence is thought to be more common, as less severe cases remain unreported. More TRALI cases are unrecognized and misdiagnosed due to lack of suspicion and absence of appropriate investigation. There are exceedingly rare reports of TRALI during plasma exchange despite the fact that liters of plasma may be used for replacement during a single procedure. We describe a mild case of TRALI during plasma exchange for thrombotic thrombocytopenic purpura in a 56-year-old woman, status post autologous hematopoietic stem cell transplant for non-Hodgkin's lymphoma. She developed severe rigors, peripheral cyanosis, hypoxia, and a transient diffuse pulmonary infiltrate. Of the 10 U of plasma used, one was from a multiparous female donor with HLA antibodies reactive with patient's granulocytes in immunofluorescence and agglutination assays. This case emphasizes the fact that the physicians and apheresis staff should consider TRALI in the differential diagnosis for patients developing respiratory distress during or soon after the procedure. Diagnosing TRALI has implications not only for the plasma exchange recipient, but also for the management of donors found to have leukocyte antibodies.

TRALI due to granulocyte-agglutinating human neutrophil antigen-3a (5b) alloantibodies in donor plasma: a report of 2 fatalities

BACKGROUND

TRALI is usually an immunologic reaction to WBC antibodies in infused plasma and ranks second only to ABO mismatch as a cause of transfusion-associated death. Implicated donors are usually multiparous women (>/=3 pregnancies).

STUDY DESIGN AND METHODS

Two fatal cases of TRALI were evaluated by reviewing clinical and laboratory findings and characterizing alloantibodies present in donor plasma. Investigation for WBC antibodies was by lymphocytotoxicity (LCT), FlowPRA (FlowPRA, One Lambda, Inc.) and granulocyte immunofluorescence and agglutination assays. Patient 1 was a 62-year-old man with chronic T-cell lymphocytic leukemia, and Patient 2 was a 54-year-old woman undergoing a cadaveric kidney transplant. Both patients developed acute respiratory distress and hypotension during (Patient 1) and approximately 30 minutes after (Patient 2) transfusion. Fulminant pulmonary edema ensued in both cases necessitating mechanical ventilation and both patients died within 24 hours of the onset of respiratory complications.

RESULTS

The donors of the implicated blood components were women with a history of two pregnancies but no blood transfusions. Weak apparently panreactive granulocyte antibodies were detected with flow cytometry. However, in the granulocyte agglutination test, strong antibodies specific for human neutrophil antigen (HNA)-3a (5b) were identified in both donors.

CONCLUSION

It is concluded that female blood donors with only two previous pregnancies can form clinically important granulocyte-reactive alloantibodies leading to fatal TRALI reactions in recipients. The sometimes devastating consequences of TRALI should prompt the development of strategies to prevent or reduce its incidence. Further research is warranted to investigate recipient and donor factors responsible for TRALI, including whether 5b (HNA-3a) alloantibodies are especially prone to cause severe reactions, and to better characterize the HNA-3a (5b) antigen, particularly at the molecular level.

Clinical manifestations of paroxysmal nocturnal hemoglobinuria: present state and future problems

The clinical pathology of paroxysmal nocturnal hemoglobinuria (PNH) involves 3 complications: hemolytic anemia, thrombosis, and hematopoietic deficiency. The first 2 are clearly the result of the cellular defect in PNH, the lack of proteins anchored to the membrane by the glycosylphosphatidylinositol anchor. The hemolytic anemia results in syndromes primarily related to the fact that the hemolysis is extracellular. Thrombosis is most significant in veins within the abdomen, although a number of other thrombotic syndromes have been described. The hematopoietic deficiency may be the same as that in aplastic anemia, a closely related disorder, and may not be due to the primary biochemical defect. The relationship to aplastic anemia suggests a nomenclature that emphasizes the predominant clinical manifestations in a patient. This relationship does not explain cases that appear to be related to myelodysplastic syndromes or the transition of some cases of PNH to leukemia. Treatment, except for bone marrow transplantation, remains noncurative and in need of improvement.

Isoimmune neonatal neutropenia due to anti-Fc(gamma) RIIIb antibody in a mother with an Fc(gamma) RIIIb deficiency

A rare case of neutropenia in a newborn due to anti-Fc(gamma) RIIIb antibody is described. The newborn, born from the 5th pregnancy, had severe infection and no neutrophils. Full clinical and neutrophil count recovery was observed when the child was 5 weeks old. In maternal serum, panreactive granulocyte alloantibodies were detected. The mother's and her two sisters' granulocytes appeared to be Fc(gamma) RIIIb deficient as found using pheno- and genotyping methods. All of them were healthy. The anti-Fc(gamma) RIIIb specificity of antibodies was identified by the monoclonal antibody immunobilization of neutrophil antigen assay. Such antibodies were not found in both sisters with the Fc(gamma) RIIIb deficiency, although they were pregnant, one of them on the seventh occasion.

New insights into paroxysmal nocturnal hemoglobinuria

The characteristic, defining defect in paroxysmal nocturnal hemoglobinuria is the somatic mutation of the PIG-A gene (essential to the biosynthesis of the glycosylphosphatidylinositol moiety that affixes a number of proteins to the cellular surface) in hematopoietic cells. These cells thus lack the proteins usually held in place by this anchor. The absence of these proteins is the most reliable diagnostic criterion of the disease and is responsible for many of the clinical manifestations of PNH. The current hypothesis explaining the disorder suggests that there are two components: (1) hematopoietic stem cells with the characteristic defect are present in the marrow of many if not all normal individuals in very small numbers; (2) some aplastogenic influence suppresses the normal stem cells but does not suppress the defective stem cells, thus allowing the proportion of these cells to increase. Current research attempts to substantiate this hypothesis and design therapy consistent with the hypothesis. Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired stem cell disorder characterized by intravascular hemolysis, hypercoagulability, and relative bone marrow failure [1]. It is characterized by a somatic mutation in the gene encoding the alpha1-6-N-acetylglucosaminyltransferase necessary for the formation of the glycosylphosphatidylinositol (GPI) anchor that binds certain proteins to the membrane surface (Fig. 1) [2,3*]. Whereas many of the manifestations can be accounted for by the absence of these proteins on the cells of the hematopoietic system, it is not entirely clear whether this defect is sufficient to make the disease manifest. In this paper, the author reviews recent clinical observations and relates them to the underlying pathophysiology of the disease.

Transfusion-related acute lung injury after the infusion of IVIG

BACKGROUND

Transfusion-related acute lung injury (TRALI) is a well-characterized, serious complication of blood component therapy in hospitalized patients. The signs and symptoms are often attributed to other clinical aspects of a patient's condition, and therefore TRALI may go unrecognized. IVIG is a pooled plasma derivative commonly used in the outpatient setting. Respiratory complications of IVIG infusion have typically been attributed to volume overload or allergic and vasomotor reactions. TRALI has never been documented to occur after IVIG infusion.

CASE REPORT

A 23-year-old man with multifocal motor neuropathy developed noncardiogenic pulmonary edema 6 hours after receiving 90 g of IVIG by a rapid-infusion protocol. He fully recovered in 5 days with nasal oxygen and bed rest. Granulocyte-associated IgG was detected in his blood 14 and 27 weeks after the event. The lots of IVIG that he received were found to contain a low-titer, panreactive, granulocyte antibody, mostly IgG.

CONCLUSION

This is the first documented case of TRALI after IVIG infusion. An autoimmune syndrome, including autoantibody-coated granulocytes, may have been a priming stimulus for granulocyte interaction with pulmonary capillary endothelium. Rapid infusion of a large quantity of granulocyte antibody may have precipitated TRALI. A pooled plasma product or derivative may result in TRALI.