Blood transfusion is a crucial life-saving treatment, but it can also cause significant side effects. To avoid unnecessary transfusions, many studies have been conducted to examine patient survival, length of stay in intensive care, and side effect profiles. These studies provide detailed guidance on when blood products should be used and when they are not necessary. Today, based on these findings, it is recommended to administer blood products only when necessary, which can enhance patient survival, decrease the risk of side effects, and promote more efficient resource use [1] .

Transfusion-associated circulatory overload (TACO) and transfusion-related acute lung injury (TRALI) are syndromes characterized by acute respiratory distress that occurs within hours or days after a blood transfusion.

The UK reported TACO (along with transfusion delays) as the leading cause of transfusion-related deaths in 2020, responsible for 30 out of 39 deaths (76.9%) [2] . Accordingly, in 2019, the Food and Drug Administration (FDA) identified TACO (along with TRALI) as the most common cause of transfusion-related deaths at 27% [3] .

TACO and TRALI remain the leading causes of transfusion-related deaths. We present a case of a potential TACO patient, a 39-year-old woman with cerebral palsy, who developed pulmonary edema after blood transfusion.

A 39-year-old female patient with a diagnosis of cerebral palsy was brought to the emergency department by her relatives due to irregular breathing and decreased consciousness compared to her baseline. She was not on any regular medication. The patient was normotensive, with a pulse rate of 120 beats/min, a respiratory rate of 35 breaths/minute, and an oxygen saturation of 93% with a reservoir mask. Physical examination revealed significant pallor, +2 pretibial edema in both legs, and rales in the left basal lung sounds. The patient’s Glasgow Coma Scale score was 8.

Laboratory results:

Hb: 1.6 g/dl RBC: 1.2 × 10¹²/L MCV: 54 RDW: 22.5

WBC: 20 × 10⁹/L Neutrophil: 20 × 10³/ml

LDH: 189 U/L CRP: 21.9 mg/L Albumin: 31 g/L

Total bilirubin: 0.3 mg/dl Direct bilirubin: 0.12 mg/dl

Blood gas:

PH: 7.219 HCO₃: 12.5 mEq/L Lactate: 13 mmol/L

Base (ecf): −13.7

Computed tomography of the thorax revealed infectious ground-glass opacities in the lower lobe of the left lung, as shown in Figure 1 . The patient was admitted to the intensive care unit, and two units of blood were transfused. Following the transfusion, the patient’s overall condition improved, and the requirement for oxygen support was eliminated. The patient was transferred to the internal medicine ward the following morning. However, three hours of post-admission, the patient developed shortness of breath, and oxygen saturation decreased to 75%. The patient was urgently transferred back to the intensive care unit and intubated. Thoracic CT angiography was performed.

In thoracic CT angiography, patchy consolidations and ground-glass opacities were predominantly observed in the lower lobes of the lungs, as shown in Figure 2 . These findings were evaluated in favor of TRALI-TACO, considering the patient’s medical history. An attempt was made to extubate the patient; however, she was unable to tolerate it. As her condition did not improve with broad-spectrum antibiotics and diuretic treatment, a tracheostomy was performed, and she continues to live on a home ventilator to this day.

The pathogenesis of TACO and TRALI is not fully understood. Two main causes have been suggested for both conditions. The first cause involves the patient’s underlying preexisting clinical condition (transfusion recipient risk factors), while the second is related to the transfused blood product. Both factors are necessary for TACO or TRALI to develop. In TACO, the first cause can be explained by poor adjustment to volume overload. A large prospective study of 200 patients with TACO found that high blood pressure, congestive heart failure, cardiomegaly on chest radiography, pretransfusion diuretic use, acute kidney injury, chronic kidney disease, and emergency surgery are risk factors associated with TACO [4] .

TACO-TRALI is rare, occurring in about 1% of blood transfusions. Although the most common cause of TACO is excessive blood product transfusion, other risk factors include heart or kidney failure, cancer diagnosis, chronic anemia, previous fluid overload, and rapid blood product administration. To prevent TACO, it is recommended to administer erythrocyte suspension (ES) replacements within 4 hours [5] . The definitions of both TACO and TRALI are shown in Table 1 and Table 2 [6] .

Unfortunately, both TACO and TRALI are potentially life-threatening, and treatment options are very limited. For TRALI, hemodynamically supportive treatments are mainly used, while for TACO, diuresis is also a key part of treatment. Blood transfusions can be lifesaving when necessary, but using them without a clear reason can pose serious, unnecessary risks to the patient. Before deciding on a blood transfusion, it’s essential to thoroughly review the patient’s history, physical exam, and any existing health conditions.

Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.