May 2022 – Transfusion Medicine

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. 

Image 1

What is the most likely diagnosis in this case?

  • TRALI (transfusion-related acute lung injury)
  • TACO (transfusion-associated circulatory overload)
  • Acute hemolytic transfusion reaction
  • FNHTR (febrile non-hemolytic transfusion reaction)

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. 


  1. AABB Technical Manual, 20th Edition, Print, 2020
    Edited by Claudia S. Cohn, Meghan Dleaney, Susan T Johnson, and Louis M. Katz

Phuong-Lan Nguyen, M.D.
Fellow, Transfusion Medicine
Mayo Clinic

Photo of Dr. Justin Kreuter

Justin Kreuter, M.D.
Consultant, Transfusion Medicine
Mayo Clinic
Assistant Professor of Laboratory Medicine and Pathology
Mayo Clinic College of Medicine and Science

MCL Education

This post was developed by our Education and Technical Publications Team.