Acute lung injury syndrome (TRALI) in a dog possibly triggered by blood transfusion

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2018-01-01

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Background: Acute Lung Injury (ALI) and the Acute Respiratory Distress Syndrome (ARDS) are clinical syndromes, differing in severity, characterized by bilateral noncardiogenic pulmonary edema, usually associated with an underlying cause. Diagnosis is given by thoracic radiography and PaO2/FiO2 ratio <300. The possible Transfusion Related Acute Lung Injury (TRALI) occurs when ALI or ARDS signs (i.e. hypoxemia and bilateral pulmonary infiltrates) are found in patients without preexisting ALI that have received transfusion in the last 72 h. This case report describes a case of a canine patient that developed possible TRALI after a forelimb amputation and a whole blood transfusion. Case: A 10-year-old female dog, with necrotic and infected bite injuries on left forelimb was initially treated conservatively with topical and systemics antibiotics. Eventually, a forelimb amputation was required, due to the soft tissue necrosis. Pre-operative complete blood count, serum biochemistry and venous blood gas analysis showed mild changes, including anemia, leukocytosis, metabolic acidosis, and increases in blood urea nitrogen, alkaline phosphatase, alanine transaminase. The patient was stable before surgery but required a post-operative whole blood transfusion to treat severe anemia. A crossmatch test was performed to reduce the possibility of transfusion reaction. Despite both surgery and hemotherapy went as expected, approximately eight hours after the transfusion, the patient developed deterioration of all vital signs, including hypotension and severe hypoxemia, with PaO2/FiO2 <126 and oxyhemoglobin saturation (SpO2) < 90% on room air. Thoracic radiographies showed mixed pattern of bilateral pulmonary infiltration. The patient's condition worsened with signs of respiratory failure, cyanosis and severe hemodynamic impairment. There was no improvement after administration of furosemide, hydrocortisone, vasoactives, supplemental oxygen and mechanical ventilation. The patient died quickly after the diagnosis, despite cardiopulmonary resuscitation efforts. Discussion: The term possible TRALI was created due to the difficulty in diagnosing the condition in patients with other risk factors for lung injuries. TRALI usually follows a two-hit model in which an underlying illness activates the endothelial cells and the transfusion activates the neutrophils causing lung damage. In this case, all four mandatory criteria for veterinary ALI occurred, namely the acute onset, systemic inflammation, pulmonary infiltrates on thoracic radiographs, PaO2/FiO2 ratio < 200 and SpO2 < 90%. The absence of cardiopathy and preexisting ALI supports the diagnosis of TRALI, which is the most frequent cause of transfusion related death in humans. Nevertheless, there are few reports of TRALI in animals making impossible to draw any conclusion about the incidence of this syndrome in veterinary patients. Differential diagnosis for TRALI is circulatory overload, anaphylaxis, bacterial contamination and acute hemolytic transfusion reaction. The treatment of ALI is focused on supportive care and on the underlying cause rather than focusing ALI as a distinct condition. The best therapeutic approach is oxygen supplementation and mechanical ventilation. Any non-ventilatory treatment approach is currently controversial. All ventilatory and pharmacological attempts in this case had no result and the patient condition declined rapidly. Since TRALI seems to be a real life-threatening entity in canine patients, a restrictive strategy for transfusion medicine should be considered.

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Acta Scientiae Veterinariae, v. 46.

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