A 60-year-old man with a history of renal failure is admitted for continuous GI bleeds. His Hb is 5.5 mg/dL (low) and his PT is 18 seconds (prolonged). The clinical team decides to treat the patient with 4 units of fresh frozen plasma (FFP) and 4 units of packed red blood cells (pRBCs) over less than 6 hours. The patient became dyspneic and hypertensive. Physical exam revealed jugular venous distension and pulmonary rales. A chest X-ray reveals bilateral pulmonary edema. Clerical check, DAT, and hemolysis check were all negative/unremarkable. The patient underwent diuretics with resolution of the symptoms within 24 hours.
The correct answer is ...
TACO (transfusion-associated circulatory overload).
Examination of the clerical check, DAT, and hemolysis check was negative/unremarkable, making acute hemolytic transfusion less likely. TRALI usually presents with fever, dyspnea, cyanosis, and hypotension, with chest X-ray showing patchy pulmonary infiltrates. In this case, the patient’s chest X-ray did not show patchy pulmonary infiltrates and did not present with fever or hypotension, making TRALI less likely. FNHTRs are typically non-life-threatening reactions which present with fever and chills toward the conclusion of the transfusion. While FNHTR can present with dyspnea and hypotension, the absence of a fever and/or chills makes FNHTR less likely.
Phuong-Lan Nguyen, M.D.
Fellow, Transfusion Medicine
Justin Kreuter, M.D.
Consultant, Transfusion Medicine
Assistant Professor of Laboratory Medicine and Pathology
Mayo Clinic College of Medicine and Science