Abstract Introduction Transfusion Related Acute Lung Injury (TRALI) is a rare reaction to blood product transfusions with less than one occurrence per ten thousand transfusions. This occurs through a two-hit process where the lung is primed by host predisposition, then blood products introduce triggers for a reaction and subsequent lung injury. Symptoms must develop within six hours of the transfusion in the absence of other insults for diagnosis. The disease has a mortality of 17%, likely higher in critically ill patients. TRALI can occur from diverse inciting events, including rhabdomyolysis, which has yet to be reported in literature. Case A 25 year old male with a past medical history of obesity, gout, and idiopathic recurrent rhabdomyolysis presented from an outside hospital for management of rhabdomyolysis with a creatinine kinase (CK) of 3352 and acute renal failure. He had five episodes of rhabdomyolysis in the past year, precipitated by COVID, upper respiratory infections, and an appendectomy. During hospitalization, he improved on hemodialysis (HD); however, due to a low serum hemoglobin level of six, he required one unit of packed red blood cells. Within a few hours of transfusion initiation, a rapid response was called for increasing oxygen requirements and he was intubated with concern for TRALI. In subsequent days, his hemoglobin continued to downtrend with a negative hemolysis workup, no overt bleeding, and with persistently high ventilator requirements. Three units of blood were given over 4 days via slow transfusions and close monitoring which successfully raised his hemoglobin above eight while maintaining a stable respiratory status. After six days, the patient was successfully extubated to nasal cannula. His renal function improved until HD could be discontinued and he was discharged with outpatient nephrology follow-up. Discussion This case highlights how a patient with multiple disease processes may accumulate predisposing risk factors and develop severe TRALI. Although the literature describes various precipitating factors that could result in TRALI, rhabdomyolysis has not been commonly reported. Using the two-hit model, literature records causes as diverse as cardiac disease, tobacco use, trauma, malignancies, and systemic inflammation as constituting a “first hit”, suggesting many patients entering the hospital are predisposed to TRALI. Understanding the pathophysiology behind TRALI and having awareness of inciting factors, providers may have a high index of suspicion for TRALI in these vulnerable patients when witnessing worsening lung function following a transfusion. This abstract is funded by: None
Weiss et al. (Fri,) studied this question.