Fatal transfusion-related acute lung injury type II following red blood cell transfusion in a cancer patient with suspected endocarditis: a case report

Transfusion-related acute lung injury (TRALI) is a potentially fatal complication of blood transfusion. The 2019 classification distinguishes TRALI type I [no acute respiratory distress syndrome (ARDS) risk factors] from type II (pre-existing or concurrent ARDS risk factors). We describe a case of TRALI type II after red blood cell (RBC) transfusion in a patient with cancer, sepsis, and suspected endocarditis. A 64-year-old woman with metastatic breast cancer on doxorubicin was hospitalized for fever and acute kidney injury. Echocardiography revealed a mobile mass on the posterior mitral leaflet with severe mitral regurgitation, and she was treated with ceftaroline and daptomycin. On hospital day 20, she received an RBC transfusion for anemia (hemoglobin 6.2 g/dL). Five hours later, she developed sudden hypoxemic respiratory failure with new bilateral infiltrates consistent with pulmonary edema, without fluid overload or cardiac decompensation. Despite non-invasive ventilation, she deteriorated and died. TRALI type II was considered the most likely diagnosis, underscoring the need for vigilance.