Chest x-rays and microscopic pathology examination of a patient with fatal TRALI. (A) Chest x-ray of the patient before surgery demonstrating low lung volumes with subsegmental bibasilar atelectasis, no evidence of pleural effusion, focal consolidation, or pneumothorax, and normal cardiomediastinal silhouette. (B) Chest radiograph at the time TRALI was recognized, which demonstrates extensive bilateral areas of consolidation in the mid and upper lobes of the lung consistent with aspiration or edema with a normal cardiac silhouette, new since the previous examination earlier on the same day. The endotracheal tube tip is 6 cm above the carina, the nasogastric tube is coiled within the hypopharynx before extending to the proximal trachea, and the right internal jugular introducer sheath tip overlies the proximal superior vena cava. These extensive areas of consolidation in mid and upper lobes are most concerning for noncardiogenic pulmonary edema. (C) Plastic-embedded histologic sections of the lungs at autopsy were stained with hematoxylin and eosin, toluidine blue, or Jones stains, and were examined by light microscopy under an OptiPhot-2 microscope equipped with a 20 ×/0.4 objective lens (Nikon, Melville, NY). Images were photographed with a Nikon CoolPix 4500 camera and acquired with Apple Mac OS × 10.3.5 (Apple, Cupertino, CA) running Portfolio 7 software (Extensis, Portland, OR). There is significant extravasation of PMNs into the alveoli and air spaces with interstitial and intra-alveolar edema (blue arrows). Toluidine blue and Jones stains demonstrate dilated capillaries and a prominence of inflammatory neutrophils in the capillaries and air spaces (yellow arrows). Histologic findings are consistent with early acute respiratory distress syndrome.