Original contributionUsefulness of empiric chest radiography and urinalysis testing in adults with acute sickle cell pain crisis
Study objective:
To determine the usefulness of obtaining routine chest radiographs and urinalyses on adults presenting to the emergency department in acute sickle cell pain crisis. The hypothesis tested is that in some adult sickle cell patients, sickle cell pain crises are precipitated or accompanied by acute infection that may be clinically occult and that routine screening for pulmonary or urinary tract infection would identify some of these precipitating illnesses.
Design:
Prospective clinical study.
Setting:
A university hospital ED.
Patients:
All patients more than 14 years old with S-S, S-C, or S-β-thalassemia sickle hemoglobinopathies who presented to the ED with acute nontraumatic painful complaints during a six-month period.
Interventions:
All patients underwent posteroanterior and lateral chest radiography, routine urinalysis, and CBC count with reticulocyte count. A standard questionnaire for localizing symptoms of systemic, pulmonary, and urinary tract infection was completed for each patient. Urine cultures were ordered on all patients with voiding symptoms, flank pain, and/or more than 5 WBCs or RBCs per high-power field on urinalysis. Physical examination for evidence of pulmonary and urinary tract infection was carefully performed and recorded for subsequent analysis.
Results:
Seventy-one patients with 134 ED presentations were studied over a six-month period. Eight diagnoses of acute pneumonia were made. Four of these patients complained of chest pain (50% vs 48% overall) and three had shortness of breath (38% vs 21%). None of these patients complained of fever or symptoms of upper respiratory illness. Ten diagnoses of urinary tract infection were made. Four of these patients complained of dysuria and frequency; three complained of flank pain. Eleven of the 18 infections (61.1%) did not have a typical history for or suggestive physical or laboratory findings of bacterial infection.
Conclusion:
In sickle cell disease patients with pain crisis, routine chest radiography and urinalysis may be clinically useful and cost effective in the early diagnosis of crisis-related infection.
References (22)
- GallowaySJ et al.
Sickle-cell anemia: A review
J Emerg Med
(1988) - LukensJN
Sickle cell disease
Disease-A-Month
(1981) - PonczM et al.
Acute chest syndrome in sickle cell disease: Etiology and clinical correlate
J Pediatr
(1985) - RogersZR et al.
Outpatient management of febrile illness in infants and young children with sickle cell anemia
J Pediatr
(1990) - RadaRE et al.
Sickle cell crisis precipitated by periodontal infection: Report of two cases
JADA
(1987) - Barrett-ConnorE
Bacterial infection and sickle cell anemia: An analysis of 250 infections in 166 patients and a review of the literature
Medicine
(1971) - BrombergPA
Pulmonary aspects of sickle cell disease
Arch Intern Med
(1974) - Konotey-AhuluFID
The sickle cell diseases: Clinical manifestations including the “sickle crisis”
Arch Intern Med
(1974) - BrozovicM et al.
Management of sickle cell disease
Postgrad Med J
(1987) - GastonMH et al.
Prophylaxis with oral penicillin in children with sickle cell anemia
N Engl J Med
(1986)
Sickle cell crises
Am J Clin Pathol
Cited by (12)
The utility of screening laboratory studies in pediatric patients with sickle cell pain episodes
2004, American Journal of Emergency MedicineThe purpose of this study was to determine whether blood counts discriminate between sickle cell pain episodes that lead to successful discharge from the emergency department (ED) and those that result in complications. This retrospective review compared the hemoglobin, reticulocyte count, and white blood cell count with differential during complicated and uncomplicated ED visits. Complicated visits were pain episodes followed by admission, by readmission within 48 hours, by acute chest syndrome, by an aplastic crisis, or by the administration of blood or antibiotics. There were 2 statistically important differences between complicated and uncomplicated pain episodes. Children successfully discharged were younger than those experiencing a complicated visit (8.9 v 11.2, P = 0.04). At a difference of 0.4 g/dL, the change in hemoglobin from baseline among children with complicated versus uncomplicated pain crises was not clinically useful. Routinely performed blood counts do not reliably identify the course of sickle cell pain crises.
Hospitalizations of adult sickle-cell patients in Guadeloupe
2000, Revue de Medecine InterneÉtudier les caractéristiques des hospitalisations pour complications aiguës chez les patients drépanocytaires adultes en Guadeloupe.
Une étude rétrospective a été effectuée chez les patients drépanocytaires suivis par le Centre caribéen de la drépanocytose (CCD). Les données ont été analysées à partir des dossiers médicaux des patients hospitalisés en 1996 au CHU de Pointe-à-Pitre et des dossiers de suivi longitudinal au CCD.
Parmi les 251 patients adultes suivis, 63 (25 %) totalisaient 87 admissions (soit1,38 hospitalisations par patient). Lâge moyen des patients hospitalisés était de 27,5 ans (de 17 à 71 ans). Vingt-neuf hommes (31 %) et 34 femmes (22 %) ont été hospitalisés ; p < 0,05. II s'agissait en majorité de drépanocytaires homozygotes : 39 patients SS (31 %) contre 19 SC (18,25 %) et cinq S β-thalassémiques (21, 75 %). Une crise vaso-occlusive douloureuse était observée au cours de 67 épisodes. Ont été notés par ailleurs neuf syndromes thoraciques aigus dont six au décours d'une crise vaso-occlusive. Un phénomène infectieux était observé dans 39 cas. Une protéine N réactive très élevée (> 100 mg/L) était associée à un syndrome thoracique aigu ou à une infection urinaire. Un patient insuffisant rénal est décédé au cours d'une septicémie.
Cette étude confirme la nécessité d'optimiser les protocoles de prévention des crises douloureuses et des complications sévères.
To determine the characteristics of acute hospitalisations in adult patient with sickle-cell disease in Guadeloupe.
We retrospectively studied clinical features of adult patients followed up by the “Centre Caribeen de la Drépanocytose” (CCD) in 1996. Data were collected from the medical records of the hospitalized patients and the longitudinal records of the CCD.
Sixty-three (25%) of the 251 patients who were followed up by the CCD required hospitalization in 87 cases (1.38 hospitalizations/patient). Mean age of the hospitalized patients was 27.5 years (range 17 to 71 years). Most hospitalizations involved men (29 [31%] vs 34 [22%] for women, P < 0.05), and most were for homozygous patients with sickle-cell anemia: 39 (31%) SS, 19 (18.55%) SC and five (21.75%) Sβ thal. A painful vaso-occlusive crisis was noted in 67 episodes. There were nine acute chest syndromes (ACS), six of them occurred following a vaso-occlusive crisis. We noted 39 infectious episodes. The increase in C-reactive protein (> 100 mg/L) was associated with ACS or urinary infection. A patient with renal failure died during septicemia.
This study confirms the need for prevention of painful crises and other severe complications in patients with sickle-cell disease.
Management of sickle cell pain crisis in the Emergency Department at Teaching Hospitals
1999, Journal of Emergency MedicineThe purpose of this study is to determine the frequency and variety of strategies being used in the Emergency Department (ED) management of sickle cell pain crisis (SCPC). One thousand randomly selected academic emergency physicians received a multiple-choice survey; 549 (55%) completed the survey. Forty-five percent of respondents treat patients with SCPC every week or almost every shift. Twenty percent use protocols for management of SCPC. Respondents consider pain refractory to outpatient treatment if it is persistent after two (23%) or three (53%) doses of parenteral analgesic. Meperidine or morphine is the most common initial analgesic. In the routine management of uncomplicated SCPC, i.v. analgesics, i.v. hydration, oxygen therapy, and complete blood counts are often or always used by 67, 71, 66, and 82% of respondents, respectively. Some patterns in the diagnostic and therapeutic management of patients with SCPC in the ED are identified, but overall practice is highly variable. Some popular elements of care are divergent from those suggested by the scientific literature.
Clinician assessment for acute chest syndrome in febrile patients with sickle cell disease: Is it accurate enough?
1999, Annals of Emergency MedicineStudy objective: To determine whether the use of empiric chest radiography (CXR) is of significant value in detecting clinically unsuspected acute chest syndrome (ACS) in febrile patients with sickle cell disease (SCD). Methods: Patients with SCD presenting to the emergency department and hematology clinic with temperature greater than or equal to 38°C were prospectively evaluated using a physician-completed questionnaire. The questionnaire included inquiries into the patient’s physical signs and symptoms and the physician’s clinical impression for the presence of ACS. The questionnaire was completed before obtaining CXR results in all patients. Results: Seventy-three patients with SCD with 96 febrile events were evaluated over a 1-year period. Twenty-four percent (23/96) of the patients had CXR evidence of ACS. On the basis of the questionnaire data, 61% (14/23) of ACS cases were not clinically suspected by the evaluating physician before obtaining CXR. Comparing the patients with and without ACS revealed that, with the exception of splinting (4/23 [17%] versus 0/73 [0%]), no symptom or physical examination finding helped to identify which patients had ACS. Fifty-seven percent of patients with ACS had completely normal findings on physical examination. The presentation of patients with clinically detected versus clinically unsuspected ACS also did not differ significantly. Length of hospitalization, oxygen use, and need for transfusion were the same in both the unsuspected and detected ACS groups. Overall physician sensitivity for predicting ACS was only 39%, and diagnostic accuracy did not improve significantly with increasing levels of pediatric training. Conclusion: ACS is common in patients with SCD who present with fever and was grossly underestimated by evaluating physicians. History and physical examination appear to be of little value in defining which febrile patients require CXR. In view of the mortality and morbidity associated with ACS, empiric CXR should be considered when evaluating a febrile patient with SCD. [Morris C, Vichinsky E, Styles L: Clinician assessment for acute chest syndrome in febrile patients with sickle cell disease: Is it accurate enough? Ann Emerg Med July 1999;34:64-69.]
Diagnostic evaluation for infectious etiology of sickle cell pain crisis
1997, American Journal of Emergency MedicineOccult infections during sickle cell pain crisis can be associated with significant morbidity. It has been suggested that empiric workup for pneumonia and urinary tract infection (UTI) is required. A study was undertaken to determine whether clinical criteria can be used to exclude such infections as precipitants of pain crisis in adults. This retrospective, observational clinical study was conducted in an inner-city teaching hospital emergency department (ED) with 95,000 visits/year. Patients 18 years of age or older presenting to the ED with sickle cell pain crisis who had not used antipyretics within 6 hours before presentation were eligible. Ninety-four visits were evaluated. During initial evaluation the treating physician completed a questionnaire addressing systemic, pulmonary, and urinary tract signs and symptoms, Temperature and physical examination were recorded on an ED memo. Treatment modalities were at the discretion of the treating physician. All patients had a complete blood count, reticulocyte count, urinalysis, and chest radiograph. If the urinalysis was positive (>2 white blood cells) or the patient had clinical evidence of a UTI, a urine culture was obtained. UTI was confirmed through a urine culture with >100,000 colony-forming units/mL. Chest X-rays were reviewed by a staff radiologist. Definitive diagnosis of pneumonia was made by the presence of an infiltrate and a positive clinical response to antibiotic therapy. Thirty-eight patients totalling 94 visits to the ED were studied during an 18-month period. Six diagnoses of pneumonia and 3 diagnoses of UTI were made. All six patients with pneumonia had at least 4 of the signs and symptoms including fever, chills, cough, shortness of breath, sputum production, chest pain, hemoptysis, abnormal pulmonary examination, and temperature of >37.8°C. Of the three patients with UTI, two had signs and symptoms inconsistent with UTI (asymptomatic bacteriuria). In patients with sickle cell pain crisis, medical history and physical examination can be useful to predict the absence of pneumonia, but may not be as beneficial in predicting the absence of UTI. These results suggest that empiric chest x-ray may be unnecessary to exclude pneumonia; however, routine urinalysis may be indicated. Because of the low incidence of these infections, larger studies are required to confirm these findings.
Pulmonary complications
1996, Hematology/Oncology Clinics of North AmericaAcute pulmonary disease has become the most common cause of death and the second most common cause of hospitalization in sickle cell disease (SCD).23, 63, 66 The term acute chest syndrome (ACS) is used to describe acute pulmonary disease in SCD in recognition that distinguishing between infectious and noninfectious causes is often difficult.3, 41, 71, 75 The diagnosis of ACS is made with demonstration of a new infiltrate on chest radiography with accompanying respiratory symptoms or chest pain.10, 68 Clinically, ACS is often more severe than pneumonia in the general population, with multilobe involvement, severe hypoxia, and rapid progression despite aggressive intervention. Diagnosis may be delayed because the presentation of ACS is variable and agedependent.8, 51, 65, 66, 69, 71
Presented at the Society for Academic Emergency Medicine Annual Meeting in Washington, DC, May 1991.