TRALI associated with HLA class II antibodies

We read with interest the article by Kopko et al.1 about the role of HLA class II antibodies in the pathogenesis of TRALI.1 We report a patient whose case strongly supports the idea that investigation of HLA class II antibodies should be included in the laboratory evaluation of TRALI. A 19-year-old woman, with a homozygous coagulation factor VII deficiency, underwent a left hepatectomy for intrahepatic lithiasis and secondary biliary cirrhosis. She received transfusion support with quarantine FFP (QFFP, which is plasma released when the donor is retested and found to have negative results for serologic markers of infection at least 6 months after the respective donation) collected by plasmapheresis (standard volume 600 mL). After uneventful surgery, the patient was admitted to the Intensive Care Unit without respirator support and stable. Seven hours after the operation and two hours after the transfusion of two units of Q-FFP, the patient became dyspneic (respiratory rate of 26 beats/min). Blood gas examination showed a sudden drop in pO2 from 133 mmHg (at FiO2 2 L/min) to 21 mmHg (normal range 75-100 mmHg) at FiO2 1.0. Prompt monitoring of central hemodynamics revealed a normal cardiac index without pulmonary hypertension. Chest X-ray showed bilateral pulmonary infiltrates and a normal cardiac outline. She did not receive invasive ventilatory support. By Day 2 in the ICU, her lung function had improved, her inspired oxygen requirements were decreased to 50 percent and a repeat chest X-ray showed clearing of the pulmonary shadows. The patient recovered without complications. Twenty-four hours after the onset of symptoms, the patient’s serum as well as two samples of the transfused plasma tested negative in a standard complementdependent lymphocytoxicity assay2 for detection of HLA class I antibodies. Granulocyte antibodies were not detected in the samples using granulocyte agglutination3 and indirect immunofluorescence.4 However, in the plasma of one of the two units of Q-FFP transfused, which was donated by a female, HLA class II antibodies were detected using an ELISA (Lambda Antigen TrayMixed [LAT-M], One Lambda, Canoga Park, CA). Since TRALI is a diagnosis of exclusion, laboratory tests provide strong support for the diagnosis. The case presented here, together with case reported by Kopko et al.1 and by Flesch et al.5 in which the infusion of a noncytotoxic HLA-DR antibody caused mild TRALI, stress the importance of testing for HLA class II antibodies in the evaluation of TRALI, especially when the tests for HLA class I antibodies are found to be negative. Marı́a Varela, MD Antoni Mas, MD, PhD Intensive Care Unit, Liver Unit Clinic Institute of Digestive Diseases Hospital Clinic Núria Nogués, PhD Blood Transfusion Center and Tissue Bank Angels Escorsell, MD, PhD, Intensive Care Unit, Liver Unit Clinic Institute of Digestive Diseases Hospital Clinic Roberto Mazzara, MD, PhD, Miguel Lozano MD, PhD, Department of Hemotherapy and Haemostasis Biomedical Diagnostic Center Agustı́ Pi i Sunyer Biomedical Research Institute Hospital Clinic Barcelona University of Barcelona, Villarroel 170 08036 Barcelona, Spain e-mail: mlozano@clinic.ub. es