NBME 24 Acute lung injury (NBME Answers)

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nbme24/Block 1/Question#6 (reveal difficulty score)
A 57-year-old woman requires intubation in ...
Acute lung injury 🔍 / 📺 / 🌳 / 📖
tags: respiratory transfusion transfusion_reactions

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submitted by ∗brethren_md(105)

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Transfusion-related acute lung injury (TRALI) is a rare but serious syndrome characterized by sudden acute respiratory distress following transfusion. It is defined as new, acute lung injury (ALI) during or within six hours after blood product administration in the absence of temporally-associated risk factors for ALI.

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drschmoctor Neutrophils sequestered in recipient lung are triggered by donor antigen (e.g., anti leukocyte IgG), which causes release of cytokines, inflammation party in the lungs. +9

madamestep It's similar to the pathophys of sepsis for ARDS! Widespread activation of inflammation fucks with the lungs +

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submitted by ∗mousie(272)

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Is 45 minutes too long to be anaphylactic and would the absence of rash (urticaria, pruritus) RO anaphylactic?

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hayayah Yes! Allergic/anaphylactic blood transfusion reaction is within minutes to 2-3 hours. (pg 114 of the 2019 FA has a list of them ordered by time) +10

hayayah (also allergy / anaphylactic presents with more skin findings (urticaria, pruritus) +9

seagull The time through me off too. I though ABO mismatch since it occured around an hour. I thought TRALI would take a little longer. +10

charcot_bouchard Guys anaphylactic reaction to whole blood doesnt occur much except for selective IgA defi. so look out for prev history of mucosal infection. And it can have all feature of type 1 HS inclding bronchospasm. +8

soph I saw hypotension and though anaphylaxis........ -.- +2

usmile1 Chest Xray showed "bilateral diffuse airspace disease". This is much more indicative of TRALI than anaphylaxis which would have wheezing and possibly respiratory arrest but no actual damage to the lungs. Additionally there was no urticaria or pruritus one would expect to see with anaphylaxis. +9

leemax you have to look out for- immediate(time is impt)reaction is Anaphylactic/allergic- you see type 1 symptoms(wheezing,urticaria). but if the reaction takes place with an hour(1)-think of type two (AntiBody mediated)-two types here , intravascular (ABO incomtability-you see hemoglobinuria and jaundine) or extravascular(DIC and + coombs). also don't forget -febrile hemolytic where cytokines that are accumulated during storage cause the reaction, here you see fever and chills. but in this question, they are asking about transfusion-related acute lung injury as seen in x-ray description, and this is due to the donor anti-leukocyte Ab acts against host neutrophils and pulmonary endothelial cells. +

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submitted by ∗unknown001(9)

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dont be distracted with timing. both can start within minutes.

how to rule out ?

anaphylaxis lung finding > WHEEZE. (question stem = no wheeze)

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