Two hours after receiving two units of packed red cells, a 79-year-old woman with ischaemic heart disease develops acute breathlessness and hypertension. She is afebrile, chest radiograph shows bilateral alveolar infiltrates with a normal-sized heart, and brain natriuretic peptide is markedly elevated. She improves rapidly after intravenous furosemide. The most likely diagnosis is:

• A Transfusion-related circulatory overload ✓
• B Transfusion-related acute lung injury
• C Anaphylactic transfusion reaction
• D Acute haemolytic transfusion reaction

Explanation

TACO typically occurs in elderly patients with limited cardiac reserve within a few hours of transfusion, producing hydrostatic pulmonary oedema with hypertension, raised BNP and prompt diuretic response. TRALI is distinguished by fever, hypotension, neutropenia and donor anti-leucocyte antibodies with a normal BNP and no response to diuresis. Anaphylaxis features bronchospasm, urticaria and hypotension rather than isolated pulmonary oedema, while acute haemolysis presents with fever, loin pain, haemoglobinuria and a positive direct antiglobulin test.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.