Is this TRALI, TACO, or just pneumonia? – a case report of acute respiratory failure

Dear Editor,
Blood transfusion carries some risk of complications. Transfusion-related acute lung injury (TRALI) is a rare but potentially fatal variant of acute respiratory failure (ARF), occurring as non-cardiogenic pulmonary oedema [1]. In patients with chronic circulatory failure, TRALI can co-exist with transfusion-associated circulatory overload (TACO). Moreover, TRALI should be differentiated from pneumonia [2].

Case PRESENTATION

A 69-year-old female patient was admitted to the intensive care unit (ICU) from the emergency department (ED) due to hypovolaemic shock resulting from massive upper gastrointestinal (GI) bleeding. On admission, the patient was cons­cious (Glasgow Coma Scale – 15 pts), in logical verbal con­tact, with circulatory failure (noradrenaline – 0.23 µg kg-1 min-1). Endotracheal intubation was performed, and mechanical ventilation was initiated. Moreover, antihemorrhagic treatment (terlipressin, tranexamic acid, calcium) and haemodynamically-guided fluid resuscitation were applied. A rescue attempt was made to manage the bleeding endoscopically, which failed. CT was performed, evidencing a haemorrhaging duodenal tumour. The patient underwent emergency Whipple surgery.
In the perioperative period, the patient required numerous transfusions of blood products (7 units of red cell concentrate, 14 units of fresh frozen plasma, 1 package of platelet concentrate, 14 units of cryoprecipitate). The patient developed circulatory failure (escalation of noradrenaline to the dose of 0.91 µg kg-1 min-1) and respiratory failure (a decrease in the Horo­witz index from 408 to 203).

Differential diagnosis

The differential diagnosis of ARF was performed, involving the cardiogenic and non-cardiogenic causes resulting from infection (pneumonia, sepsis) and the effects of non-infective factors (aspiration of gastric content, pancreatitis, post-transfusion complications, pneumothorax, pulmonary embolism, intra-alveolar haemorrhage).
Bedside X-ray revealed massive, mottled shades located on both sides of perihilum areas (Figure 1A). Echocardiography (the FATE protocol) demonstrated a normal left ventricular systolic function and the presence of low amounts of fluid in both pleural cavities. The size of cardiac cavities was normal. Collapse of the inferior vena cava was slight. Ultrasound of the lungs (the BLUE protocol) disclosed the profile B with the visible sliding sign. The parameters of haemolysis were...


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