Transfusion related acute lung injury (TRALI) after plasma exchange in myasthenic crisis

Transfusion-Related Acute Lung Injury (TRALI) is an uncommon but potentially fatal reaction that is both temporally and mechanistically related to receiving allogenic blood components. Although many patients with neurological disease receive plasma exchange, TRALI in a patient receiving plasma exchange for a neurological disease has not been previously reported.

A 79-year-old woman with an 18-month history of myasthenia gravis, was treated with a 4-day course of plasma exchange for symptomatic control of ptosis, diplopia, generalized fatigue, and chewing difficulties. On her fourth day of receiving plasma exchange, she experienced sudden-onset chest heaviness, diaphoresis, and dyspnea with hypoxemia, unresolved by 5 l of oxygen via nasal cannulae. She was initially investigated for a myocardial infarction and pulmonary embolus, but these were ruled out. Chest radiograph demonstrated bilateral pulmonary edema and she was clinically diagnosed with TRALI.

Although clinically identical to adult respiratory distress syndrome (ARDS), the association of TRALI with transfusion and its relatively lower mortality rate made it clinically distinct. Treatment is supportive, but patients who tolerate the initial reaction are likely to make full recovery within 72 h. Since prognosis can be excellent, identification and emergent management is essential, particularly in patients with comorbid neurological disease.