A transfusion medicine physician in Israel reports having recently seen a nulligravid 15 year old girl with refractory ITP who was treated by her pediatric hematologist with IV anti-D at a dosage of 50 mcg/kg. Four hours after receiving the anti-D she complained of weakness, chills and dyspnea. In an ER she had an O2 saturation of 88%, tachycardia, crackles over both lung bases and mild bilateral pulmonary infiltrates on chest xray. A cardiac echo was normal and she had minimal hemolysis (a drop of 1 g/dL hemoglobin over the following 48 hours with no overt intravascular hemolysis). She was treated with supplemental O2 by nasal prongs only. Within 24 hours the clinical syndrome had abated and O2 sat and xray were normal. The Israeli colleague is entertaining the possibility of TRALI, but wonders if other colleagues have suggestions for an alternative diagnosis. He asks two questions:

1. Do others have experience with diagnosing TRALI following administration of IV anti-D for treatment of ITP?
   
   
2. Could anybody help him with analysis of serum collected from the patient after she developed this complication, and a vial of anti-D from the batch that she received? He laments that he does not have facilities to test for white cell (neutrophil, monocyte, HLA) antibodies.

The following comments have been received.

1. A transfusion medicine physician in Irvine, California submits references to previously reported cases of TRALI after IVIg:

• Rizk A et al. Transfusion, Feb 2001
• Cailleux N et al. Rev Med Interne, June 1998

ADDENDA Sept 29, 2004

2. A colleague in the USA reports that she is aware of two granulocyte testing laboratories in the USA and one in Europe.

In the USA:

• An American Red Cross, North Central Blood Services, located in St. Paul, MN, . The lab supervisor is Randy Schuller; phone 651-291-6797.
• Blood Center of Southeastern Wisconsin in Milwaukee, WI. The technical director is Brian Curtis; phone 800 245-3117, ext 6255
  

In the UK:

• A National Blood Service laboratory in Bristol UK, The contact person is Geoff Lucas; phone 0117-991-2129.

3. A colleague in Europe believes that the laboratory of Jürgen Bux in Hagen, Germany, may also be able to help the Israeli physician.

4. A colleague at the Red Cross in Australia reports that they have a team with particular interest in TRALI, and expertise in neutrophil immunobiology. Contact information: Lin Fung, Granulocyte Scientist, The Innovation Laboratory, Knowledge & Innovation, ARCBS, Tel: 61-7-3833 1652 or 3835 1310, Fax: 61-7-3832 6025.

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Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator