Abstract Introduction We present a case of acute pulmonary hemorrhage in a patient with chronic lymphocytic leukemia (CLL) after a blood transfusion. Autopsy revealed concern for invasive aspergillosis. Case Presentation A 64-year-old man with a history of CLL, not on maintenance therapy, was admitted for neutropenic fever due to sinus infection and was started on piperacillin/tazobactam. Due to hypogammaglobulinemia, he received intravenous immunoglobulin. He was also resumed on neutropenic prophylaxis with acyclovir, fluconazole, and levofloxacin. His condition gradually improved, and on day nine of hospitalization, he was stable for discharge. Before discharge, one unit of packed red blood cells was ordered for hemoglobin 8 g/dL. Approximately 20 minutes after transfusion, he developed supraventricular tachycardia with heart rates in the 200s, requiring IV metoprolol and adenosine for rate control. Chest X-ray was unremarkable. He subsequently developed acute respiratory distress requiring escalation to the intensive care unit for intubation and mechanical ventilation. Bronchoscopy revealed bilateral large-volume bloody frothy secretions from all lobes of the lungs. The patient rapidly deteriorated and developed refractory shock requiring multiple vasopressors, multiorgan failure, metabolic acidosis, and anuria. He expired six hours after the transfusion. Autopsy demonstrated bilateral pulmonary hemorrhage, diffuse alveolar hemorrhage, and angio-invasive aspergillosis. Discussion There was uncertainty regarding the cause of death of our patient. TRALI was considered due to the rapid decline after transfusion. However, his presentation did not meet the CDC National Healthcare Safety Network criteria. TRALI is extremely rare and occurs in approximately 1 in 12,000 units. It tends to present with bilateral infiltrates, which were not seen initially and is also rarely associated with pulmonary hemorrhage. Furthermore, TRALI was thought to involve neutrophil activation leading to cytokine release and systemic vasodilation. This was considered unlikely in our patient who was neutropenic. The cause of death was deemed to be due to invasive aspergillosis per autopsy report. Our patient had discontinued CLL therapy and prophylaxis months prior to admission. His immunocompromised status pre-disposed him aspergillosis, which frequently causes pulmonary hemorrhage. Notably, fluconazole, which was restarted on admission, is ineffective against aspergillosis as opposed to Posaconazole, which is also used for prophylaxis. Conclusion Patients with prolonged neutropenia are at risk for aspergillosis and pulmonary hemorrhage. Fluconazole, while useful for prophylaxis, is ineffective against aspergillosis. Therefore, Posaconazole should be considered as prophylaxis for patients with prolonged neutropenia. This abstract is funded by: NA
Leatheng et al. (Fri,) studied this question.