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TRALI: Leukopenia

TRALI: a inflammatory (non-hydrostatic) pulmonary edema Characterized by:

  • acute respiratory distress
  • hypoxemia
  • hypotension
  • fever
  • widespread pulmonary infiltrates
  • The majority of cases occur within minutes

Most are within 1-2 hours, but must be <6 hours after blood product transfusions to qualify as TRALI

  • Happens in 1/5000 blood product transfusions
  • Leading cause of transfusion-related mortality
  • Occurs at all age groups and equally in both sexes
  • Increased susceptibility in the critically ill
  • All blood components have been associated with TRALI
  • Greatest incidence with plasma-rich components such as: plasma, platelets, and whole blood
  • Generally thought to occur via a two-hit hypothesis:
  • Neutrophil sequestration and priming: endothelial damage, etc. leads to increased adhesion molecules in the vasculature of the lungs, and they are primed by cytokine release
  • Neutrophil activation: Sequestered neutrophils are activated by donor anti-leukocyte antibodies or bioactive lipids
  • TRALI rarely occurs in neutropenic patients

Leukopenia in TRALI

  • Following pulmonary sequestration of neutrophils, there is a transient neutropenia
  • Nakagawa M, Toy P: Acute and transient decrease in neutrophil count in transfusion related acute lung injury: Cases in one hospital. Transfusion 2004; 44:1689–1694
  • A white blood cell count should be obtained immediately on recognition of the signs and symptoms, because the leukopenia is transient (Ref. 1)
  • The amount of leukopenia reported in some case reports is from 8% to 30% of the pre-TRALI WBC (Ref. 2)
  • The time of duration, as stated in some case reports, is a gradual increase back to baseline over 6-10 hours. (Ref. 2)
  • No other acute transfusion reaction is accompanied by leukopenia


  1. Pearl Toy, Mark A Popovsky, Edward Abraham, Daniel R Ambruso, Leslie G Holness, Patricia M Kopko, Janice G McFarland, Avery B Nathens, Christopher C Silliman, David Stroncek, National Heart, Lung and Blood Institute Working Group on TRALI Transfusion-related acute lung injury: definition and review. Crit. Care Med.: 2005, 33(4);721-6 Link
  2. Marisa B Marques, Hande H Tuncer, Stephen G Divers, Allyson C Baker, D Keith Harrison Acute transient leukopenia as a sign of TRALI. Am. J. Hematol.: 2005, 80(1);90-1 Link