Sickle Cell Disease - Pneumonia

5/05/00 (Del Rio)

Group: Friday Interns

RE: A 19 year old male with sickle cell disease and suspected pneumonia.

Question: What problems are presented in the diagnosis of pneumonia in sickle cell disease?

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Fulltext Available in MDConsult using Journal Search and the search term: 97292937

Unique Identifier: 97292937

Authors: Ander DS. Vallee PA.

Institution: Division of Emergency Medicine, Emory University, Atlanta, GA 30303, USA.

Abstract: Occult 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 degrees 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.

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Unique Identifier: 92060195

Authors: Pollack CV Jr. Jorden RC. Kolb JC.

Institution: Division of Emergency Medicine, University of Mississippi Medical Center, Jackson 39216-4505.

Abstract: 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-beta-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.