P1.021: Transfusion-Associated Circulatory Overload in a Pediatric Patient with Severe Anemia due to Chronic Malnutrition

Introduction: Transfusion-associated circulatory overload (TACO) is a serious but underrecognized transfusion complication, characterized by acute respiratory distress, pulmonary edema, and hemodynamic instability. While well-documented in adults with comorbidities, TACO remains poorly characterized in pediatric patients, particularly those with chronic anemia due to malnutrition. This case highlights the importance of cautious transfusion strategies in this vulnerable population.

Case Description: A 6-year-old female with Cornelia de Lange syndrome and chronic malnutrition presented with fever, vomiting, and right-sided weakness. She was tachycardic, tachypneic, hypertensive, and febrile, with an S3 gallop and hepatomegaly. Laboratory results revealed severe anemia (hemoglobin 2.1 g/dL), elevated lactate (6.0 mmol/L), and procalcitonin (9.0 ng/mL). Chest X-ray showed diffuse interstitial opacities, and echocardiography revealed mild mitral regurgitation with moderate left atrial dilation. She received a 15 mL/kg packed red blood cell transfusion over eight hours.
Following transfusion, she developed worsening respiratory distress with tachypnea, rales, and increased work of breathing, requiring escalation to BiPAP and subsequent emergent intubation for hypercarbic respiratory failure. Post-intubation imaging showed bilateral pulmonary consolidations and frothy secretions. Elevated BNP and positive fluid balance confirmed the diagnosis of TACO. Management included aggressive diuresis with albumin and furosemide, fluid restriction, chest physiotherapy, and frequent suctioning. Given persistent anemia, two additional transfusions of 5 mL/kg over four hours each were administered with concurrent diuresis. The patient tolerated these transfusions well, was successfully extubated, and demonstrated clinical improvement.

Discussion: This case highlights the risk of TACO in pediatric patients with severe anemia and malnutrition. The overlap of transfusion-related complications and underlying high-output heart failure poses diagnostic and therapeutic challenges. Unlike in adults, standardized pediatric guidelines for TACO management are lacking. Our experience suggests that cautious transfusion strategies, including small-volume transfusions with concurrent diuresis, may mitigate complications in high-risk pediatric patients.

Conclusion: TACO should be considered in pediatric patients with severe anemia who develop respiratory distress post-transfusion. Early recognition and targeted management, including judicious transfusion volumes and proactive diuresis, can improve outcomes. This case adds to the limited pediatric TACO literature and underscores the need for further research to establish evidence-based guidelines for transfusion in this population.