Case 700 -- A 55 year-old male with weakness and altered mental status

There was a strong suspicion for thrombotic thrombocytopenic purpura (TTP). Disseminated intravascular coagulation (DIC) was considered, but his DIC panel showed no significant D-dimer and a normal fibrinogen level. The peripheral smear (image 1) showed schistocytes and helmet cells consistent with microangiopathic hemolysis. The patient readied for plasmapheresis as treatment. Given his worsening International Normalized Ratio (INR), he also received a total 10 units of fresh frozen plasma over the initial course of his admission. During plasmapheresis, hypotension was noted. His blood pressure improved after 700 mL of IV normal saline and vasopressors were given, but the patient became hypotensive again. Plasmapheresis was eventually stopped. He became progressively hypoxic and respiratory rate decreased. Six hours later, cardiopulmonary arrest ensued. His pulse was regained after 10 minutes of advanced cardiac life support. Suctioning of stoma was not significant for blood or secretions. A STAT chest x-ray showed bilateral pulmonary edema and a small right lower lobe infiltrate. His BNP level was greater than 5000 pg/mL. A blood bank workup for hemolysis was negative.

The clinical teams initiate a request to the blood bank, to assess the possibility of a transfusion reaction.

Additional laboratory studies are as follows:

His vital signs at the beginning and after completion of plasmapheresis were as follows:

Which two processes best account for this patient's deterioration after plasmapheresis?

  1. Sepsis
  2. Delayed hemolytic transfusion reaction
  3. Transfusion associated acute lung injury (TRALI)
  4. Transfusion associated circulatory overload (TACO)
  5. Thrombotic thrombocytopenic purpura (TTP)
  6. Severe allergic reaction / anaphylaxis

Case Continues

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