Acute exacerbation of subclinical pulmonary fibrosis after red blood cell transfusion: a case report

Abstract

Background Red cell transfusion is associated with lung injury in susceptible hosts, although many cases do not meet criteria for transfusion related acute lung injury. Patients with underlying pulmonary fibrosis can exhibit precipitous deteriorations in respiratory status of unknown etiology defined as acute exacerbations due to superimposed lung injury syndrome. It is unclear whether red cell transfusion is associated with acute exacerbation of underlying pulmonary fibrosis. Case Report We describe a patient who underwent an uneventful elective left total hip replacement but developed anemia post-operatively. Twenty-four hours following transfusion of her fifth non-leukoreduced AS-5 red cell unit, she developed new bilateral airspace infiltrates associated with progressive hypoxemia. These RBC units were 35-38 days old. Despite supportive care and diuresis, patient remained profoundly hypoxemic with infiltrates that progressed to fibrosis. Results The patient had mild sub-clinical lower-lobe predominant interstitial pulmonary fibrosis but developed diffuse bilateral ground glass opacities with areas of consolidation 24 h after receiving her last RBC unit. Transbronchial biopsy of the right lower lobe showed active organizing pneumonia and underlying interstitial fibrosis, supporting the clinical diagnosis of acute exacerbation of pulmonary fibrosis. The bronchoalveolar lavage showed progressive bloody effluent, consistent with diffuse alveolar hemorrhage, a marker of lung injury. There was no evidence of viral inclusions, fungal elements, pneumocystis, or bacterial organisms. Conclusion Transfusion of multiple units of aged RBCs was temporally associated with an acute exacerbation and rapid progression of underlying sub-clinical pulmonary fibrosis.

Acute exacerbation of interstitial lung disease after procedures

“…Interestingly, this patient was not intubated for his procedure, eliminating barotrauma or atelectatrauma as possible etiologies for his presumed exacerbation. Other cases of possible AE-ILD after non-pulmonary surgeries have occurred in the presence of multiple blood transfusions or other pro-inflammatory states, which may cloud the post-operative recognition of AE-ILD [43].…”