Transfusion-Related Acute Lung Injury (TRALI) Following Intravenous Immunoglobulin (IVIG) in a Liver Transplant Recipient: A Case Report

Background: Transfusion-related acute lung injury (TRALI) is a severe, life-threatening reaction to blood product transfusion. While it is most often linked to plasma, platelets, or red blood cells, cases following intravenous immunoglobulin (IVIG) are exceedingly rare and under-recognized. Reporting such occurrences is vital to raise awareness among clinicians, especially when managing high-risk patients such as transplant recipients. Case Presentation: A 35-year-old man, two months after liver transplantation, was admitted with abdominal pain and diarrhea. He was receiving immunosuppressive therapy and was diagnosed with cytomegalovirus (CMV) colitis. After transfusions of packed red blood cells and fresh frozen plasma for anemia, he was started on IVIG as adjunctive therapy. Within minutes of the first IVIG infusion, he developed severe respiratory distress, hypoxemia, and bilateral pulmonary edema requiring mechanical ventilation. Despite initial stabilization, a subsequent IVIG rechallenge (20 mL; Kedrion 5 g/100 mL) triggered bradycardia and recurrent respiratory failure. With other causes excluded, IVIG-related TRALI was diagnosed according to the 2019 Delphi criteria. Despite intensive supportive care, the patient died. Conclusions: This case highlights that TRALI can occur as a rare but fatal complication of IVIG therapy. Clinicians should maintain a high index of suspicion, particularly in immunocompromised or critically ill patients. Prompt recognition and immediate discontinuation of IVIG are essential. Further research is needed to better understand the underlying mechanisms and risk factors of IVIG-associated TRALI.