Endgames Case Review

Now you see it, now you don’t

BMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i3714 (Published 21 July 2016) Cite this as: BMJ 2016;354:i3714
  1. Lauren Berg, foundation year 1 trainee1,
  2. Anietie Ekong, clinical fellow in haematology1,
  3. Susan Rowe, consultant radiologist1,
  4. Dimitris A Tsitsikas, consultant haematologist1
  1. 1Homerton University Hospital NHS Foundation Trust, London, E9 6SR, UK
  1. Correspondence to: L Berg lauren.berg09{at}imperial.ac.uk

A 40 year old black British man with known sickle cell anaemia presented to the emergency department with a nine hour history of left-sided pleuritic chest pain. The patient also had pain in both arms and legs. Three weeks earlier, he had had a productive cough treated with oral antibiotics in the community. A chest radiograph at that time showed no consolidation, and his symptoms had since resolved.

On admission, he reported excruciating pain, his oxygen saturations were 81% on air, and his respiratory rate was 30 breaths/min. Clinical examination was unremarkable except for reduced air entry throughout the lung fields, and he was apyrexial. His haemoglobin level was 60 g/L (baseline 69 g/L) and white cell count was 23 × 109/L with neutrophilia. His ECG showed no ischaemic changes. His admission chest radiograph can be seen in figure 1 (left).

Fig 1 Patient’s chest radiographs: at presentation (left), and 36 hours later (right)

He was treated with high flow oxygen, intravenous fluids and both simple and opioid analgesia. Four hours later he was more settled, his respiratory rate had decreased, and widespread crepitations—worse on the right—had developed. The patient was admitted to the haematology ward and received automated red cell exchange transfusion, oxygen therapy, intravenous fluids, analgesia, incentive spirometry, and antibiotics.

Figure 1 (right) shows his second chest radiograph, performed 36 hours later.

Questions

  1. What are the diagnosis and differential diagnoses?

  2. What improvements does the second radiograph show, and why have they occurred?

  3. What is the long term management of a patient such as this in the community and in the specialist haematology setting?

Answers

1. What are the diagnosis and differential diagnoses?

Short answer

The diagnosis is acute chest syndrome. Differential diagnoses include pulmonary embolism and vaso-occlusive crisis of the ribs.

Discussion

Acute chest syndrome (ACS) is an acute illness characterised by fever or respiratory symptoms, or both, accompanied by a …

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