Post-mortem analyses in two cases of transfusion-related acute lung injury (TRALI) and literature review.

TRALI (Transfusion-related acute lung injury) is a life-threatening event occurring within six hours post-transfusion, characterized by non-cardiogenic pulmonary edema and severe respiratory distress. It holds particular importance in forensic and medicolegal contexts due to its rapid onset and clinical severity. This study describes two autopsy-confirmed TRALI cases: an 89-year-old man (Case 1) with leukemia who developed acute respiratory symptoms during a home transfusion, and a 63-year-old man (Case 2) who suffered bronchospasm and arrest after receiving erythrocyte units during orthopedic surgery. Post-mortem findings involved congested, edematous lungs with increased weight and volume. Microscopy revealed pronounced capillary congestion, erythrocyte stasis, and abundant neutrophils identified with CD15 immunostaining, while alveolar spaces showed focal edema, scattered neutrophils, fibrin deposition, and patchy hyaline membranes. Transmission electron microscopy highlighted cholesterol crystal ghosts in Case 1 and additional fibrin, while in Case 2 only degranulated neutrophils were identified. These findings, correlated with the clinical context, confirmed TRALI type 1. Our cases were compared with TRALI fatalities described in literature, retrieving only 9 with complete post-mortem analyses. Accurate post-mortem diagnosis is crucial for forensic pathologists investigating fatalities after transfusions, ensuring proper accountability and highlighting the necessity of integrating clinical history with pathological data to determine the cause and manner of unexpected post-transfusion deaths.