|Year : 2019 | Volume
| Issue : 2 | Page : 102-104
Transfusion-Related acute lung injury in a patient with hellp syndrome: A case report
Ranjana S Kale, Priyanka D Gorjelwar
Department of Pharmacology, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra, India
|Date of Submission||21-Mar-2019|
|Date of Decision||09-Jul-2019|
|Date of Acceptance||11-Jul-2019|
|Date of Web Publication||06-Sep-2019|
Dr. Priyanka D Gorjelwar
Department of Pharmacology, Mahatma Gandhi Institute of Medical Sciences, Sevagram - 442 102, Maharashtra
Source of Support: None, Conflict of Interest: None
Transfusion-related acute lung injury (TRALI) is a serious adverse reaction associated with the transfusion of plasma-containing blood components, and presents as hypoxemia and non-cardiogenic pulmonary oedema within 6 hrs of transfusion. Here we are reporting a case of TRALI in 24-year-old pregnant Female presented with HELLP (haemolysis, elevated liver enzymes, and low platelet count) syndrome, an emergency caesarean section delivery was performed, and blood was transfused. In such cases, clinicians should strictly monitor the patient's condition at least during the 6 hrs while the patient receives blood transfusion, and should suspect TRALI. The patient's rapid clinical deterioration with falling O2 saturation and other respiratory symptoms after transfusion supports the diagnosis of TRALI.
Keywords: Acute lung injury, blood transfusion, caesarean section, HELLP syndrome, transfusion-associated circulatory fluid overload
|How to cite this article:|
Kale RS, Gorjelwar PD. Transfusion-Related acute lung injury in a patient with hellp syndrome: A case report. J Obstet Anaesth Crit Care 2019;9:102-4
|How to cite this URL:|
Kale RS, Gorjelwar PD. Transfusion-Related acute lung injury in a patient with hellp syndrome: A case report. J Obstet Anaesth Crit Care [serial online] 2019 [cited 2019 Sep 19];9:102-4. Available from: http://www.joacc.com/text.asp?2019/9/2/102/266139
A 24-year-old pregnant female patient second gravida (G 2 P 1 L 1) was admitted with H/O amenorrhea since 9 months in the OBGY maternity ward I/V/O previous scar in labor; emergency lower segment cesarean section (LSCS) was done on 24th December, and the procedure was uneventful. On postoperative day 7, the patient started complaining of abdominal pain and tachycardia. Her vital signs were as follows: blood pressure (BP) 130/70 mmHg, pulse rate 114/min, respiratory rate 20/min, and body temperature 36.9°C.
On investigation, it was found that her liver enzymes were elevated, platelet counts were reduced, and total bilirubin was increased. The patient was then shifted to medicine intensive care unit and was diagnosed with HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) [Table 1]. The patient was transfused two units of platelet concentrates and four units of fresh frozen plasma.
|Table 1: Laboratory findings of patient confirming the HELLP syndrome and TRALI|
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On day 9, she was transfused seven units of platelet concentrates and five units of fresh frozen plasma. At 6 h of transfusion, rapid clinical deterioration was noted with a falling oxygen saturation (SPO2 <80%), tachycardia (pulse rate >110/min), and tachypnea (RR >30/min), with normal BP and temperature.
An urgent chest X-ray was ordered which showed bilateral pulmonary infiltrates [Figure 1]. Her hemodynamic parameters progressively worsened with onset of respiratory distress. The patient was given dexamethasone stat and was supported with mechanical ventilation using a positive end expiratory pressure of 17 mmHg. She was on NIV support, FiO2 45%. Over a period of 24 h on day 11, the patient responded to symptomatic measures. Her hemodynamic parameters improved. X-ray showed clearance of pulmonary infiltrates after 24 h of ventilator support. Hence, a possibility of transfusion-related acute lung injury (TRALI) was raised.
|Figure 1: (a) Chest X-ray findings at the time of acute symptoms (b) Chest X-ray findings after 2 days treatment|
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The patient's clinical features, course of events, and response of the acute episode to supportive management were all supportive of this diagnosis. The patient eventually recovered completely from this acute pulmonary insult over the course of the next few days and was discharged from hospital care after 15 days.
| Discussion|| |
TRALI is the third leading cause of transfusion-related mortality; however, it is often underdiagnosed and underreported.
TRALI was defined based on clinical and radiological parameters at the 2004 Consensus Conference, as newly developed ALI/acute respiratory distress syndrome (ARDS) within 6 h of a blood products transfusion [Table 2].
The mechanism that initiates TRALI is still a matter of discussion and there is no explicit recommendation for how to act in case of a suspected transfusion-related acute lung reaction. However, there are studies that suggest the likelihood of stepwise, two-event “two-hit” mechanism. The first “trigger event” being associated with the underlying clinical condition causes a sequestration and activation of neutrophils in the pulmonary capillaries where the transfusion of antibody-rich blood products is the second trigger causing an extensive release of vasoactive mediators.
The lack of recognition of this injury can result in inappropriate treatment, as well as failure to report the reaction to the transfusion centers and the blood collection facility. As distinctive biomarkers are absent, TRALI is a clinical diagnosis.
Unfortunately, the signs and symptoms associated with TRALI can easily be confused with those of other conditions, including transfusion-associated circulatory fluid overload (TACO), pneumonia, and ARDS. The key point in the differentiation of TRALI from the other types of pulmonary edema is that the pulmonary edema in TRALI is non-cardiogenic and that the patients do not show volume overload. The treatment for TRALI includes maintenance of the hemodynamic status and application of ventilatory support. The differential diagnosis of TRALI is important, because aggressive diuretic therapy can result in further hypotension, shock, and death. During or within 6 h of transfusion, irrespective of the amount of blood or blood products transfused, if a patient shows acute-onset dyspnea, clinical differential diagnosis of TRALI and TACO should be first made. Thereafter, a decision should be taken whether the hemodynamic status should be maintained and ventilatory support applied in the event that TRALI is diagnosed, or diuretic therapy be administered in the event that TACO is diagnosed.
Especially, the possibility of transfusion is high when a patient with the HELLP syndrome is scheduled for an emergency caesarean section delivery.
HELLP syndrome is a serious complication in pregnancy characterized by hemolysis, elevated liver enzymes, and low platelet count occurring in 10%–20% of cases with severe preeclampsia.
About 70% of such cases develop before delivery, the majority between 27th and 37th gestational weeks, and the rest within 48 h after delivery. It was reported that 46.03% of patients with HELLP syndrome required transfusion of blood or blood products.
In this case, after the cessation section the liver enzymes were elevated, platelets were reduced, and total bilirubin was increased [Table 1]. All these findings confirmed the diagnosis of HELLP syndrome. Then the transfusion was done and the patient developed dyspnea at 6 h after the transfusion. Chest X-ray was done immediately [Figure 1]. (A) Chest radiography, conducted 2 h after transfusion, showed bilateral lung infiltrations. (B) Chest X-ray, conducted 2 days after transfusion, showed reduction in the active lung lesion. This confirmed the diagnosis with TRALI and administered treatment with supplemental oxygen.
This case of TRALI after the caesarean section delivery in a 24-year-old pregnant woman with HELLP syndrome is unique. First, HELLP syndrome is rare and occurs in approximately 0.5%–0.9% of pregnancies overall.
In cases where the HELLP syndrome is accompanied by TRALI, the latter condition would be unnoticed if not suspected clinically and could result in hypotension or shock if it is misdiagnosed as TACO, followed by administration of aggressive diuretic therapy.
However, the patient's condition was closely observed during the blood transfusion and suspected TRALI accompanying the HELLP syndrome. Furthermore, hemodynamic status were maintained and supplemental oxygen was provided without administration of a diuretic therapy. Second, mechanical ventilation is important for the treatment of patients with TRALI.
Looney et al. reported that 91% of the patients with TRALI were treated with mechanical ventilation, and that 78% of the patients who developed edema required new mechanical ventilation. However, in this case, the patient responded to supplemental oxygen and mechanical ventilation and completely recovered.
Third, to our knowledge, a well-documented report of TRALI accompanying the HELLP syndrome is lacking. We searched for reports using terms related to TRALI and the HELLP syndrome on PubMed and found only one report.
In India, we experienced this as a unique case of TRALI after caesarean section delivery in a 24-year-old patient with HELLP syndrome.
In conclusion, clinicians should closely observe the patient's condition at least during the 6 h while the patient receives blood transfusion, suspect TRALI if the patient complains of respiratory symptoms such as dyspnea, and perform echocardiography to differentiate between the different types of transfusion-related adverse reactions, and each suspected case should be reported to the blood transfusion center for leukocyte antibody screening in the recipient's and donor's blood to reduce the mortality and morbidity in patients.
This case report was supported by Mahatma Gandhi Institute, Sevagram. Priyanka D. Gorjelwar would like to thank her guide Dr. Ranjana S. Kale from Pharmacology Department who provided insight and expertise that greatly assisted this study. The authors together thank Medicine Department for their support that greatly improved the article.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]