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A 74 year old woman presented with hematemesis. Her medical history was significant for pulmonary embolism treated with warfarin anticoagulation, fibromyalgia treated with NSAIDs/steroids, and a prior bleeding event from a gastric ulcer. On admission she was stable with a hemoglobin of 8.7 g/dL and a therapeutic INR of 3.19. A type and screen determined a blood type of AB positive. In anticipation of endoscopy, the patient received one unit of red blood cells and four units of type AB plasma. Following transfusion, her INR was 1.83. The patient received an additional four units of type AB plasma to further correct her INR. Endoscopy identified a medium-sized gastric ulcer. Shortly after completion of the endoscopy, the patient became hypoxic and began experiencing dyspnea and frothy oral secretions. A chest x-ray 1 hour after the start of the reaction showed diffuse pulmonary edema without cardiomegaly (image 1). The patient was intubated within 2 hours of the reaction and a chest x-ray showed increasingly diffuse pulmonary edema with small bilateral pulmonary effusions (image 2). Ventilator and pressor support were required for several days, and the patient was extubated five days after the reaction. The clinical team and transfusion service strongly suspected Transfusion Related Acute Lung Injury (TRALI) and contacted the blood supplier. The blood supplier determined the Human Leukocyte Antigen (HLA) Class I/II type of the patient and pursued HLA antibody screening for the donors of the four plasma units transfused most proximal to the reaction. Three of the four donors were parous females and returned for HLA antibody screening, while the fourth male donor could not be contacted. Of the three tested donors, none had Human Neutrophil Antigen (HNA) antibodies. Two of the three tested donors had HLA Class I/II antibodies that were non-cognate with the patient. One of the three tested donors had extensive HLA Class I/ II antibodies which were cognate with 4 of 6 of the patient’s HLA Class I antigens and 4 of 6 of the patient’s Class II antigens. The implicated donor was deferred from further donation.

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