70 yo M who presents with dyspnea after a platelet transfusion

Case and images courtesy of Dr. Shannon McCounnaughey.


  • Initial management of a patient with suspected transfusion reaction


A 70 yo M with a history of atrial fibrillation, polycythemia vera who presents with dyspnea following a platelet transfusion. He received 1 pack of platelets in for a platelet count of 29k in anticipation of a dental procedure. Near the end of the transfusion (~ 1.5 – 2 hours after initiation of transfusion), he developed acute onset shortness of breath, shaking chills, chest tightness and palpitations. He otherwise denied any rash, pruritis, tongue or lip swelling, chest pain. Prior to the procedure, he was in his usual state of health.

His PMH is additionally notable for reactive airway disease, mildly depressed LVEF of 40-45% on most recent TTE from ~ 6 months prior. His medications include Augmentin (started for a dental infection), Advair, metoprolol, and ruxolitinib.

What would you do now? 


On exam, he is febrile to 38.3C, HR 164, RR 2, BP 96/30 (baseline is normal). SaO2 84% on RA, which improved to 96% on 6L NC. He has increased work of breathing, diffuse crackles in his bilateral bases, no wheezes, or rhonchi.  He had no notable lip or tongue swelling and had an open posterior oropharynx. Cardiac exam is notable for JVP of 7 mmHg, no LE edema. He had scattered petechiae in his extremities but no raised wheals.

What is your differential? (~ 5 min) 

What is your next step in evaluation and management? (~ 5 min)


How does this change your differential? 


How do you differentiate between these two types of pulmonary transfusion reactions? 

What is the management of this patient’s diagnosis?  

See the Additional Learning Section below to learn more about the two hit hypothesis (pathogenesis of TRALI) and prevention measures.



What is the two hit hypothesis? 

How do you prevent TRALI? 


  1. Delaney, M, et al. 2016. “Transfusion reactions: prevention, diagnosis, and treatment.” Lancet. 388: 2825-2836.
  2. Roubinian, NH, et al and the TRALI Study Group. 2017. “Differentiating pulmonary transfusion reactions using recipient and transfusion factors.” Transfusion. 57: 1684-1690.
  3. Looney, MR, Gropper, MA & Matthay, MA. 2004. “Transfusion-Related Acute Lung Injury.” CHEST. 126: 249-258.