Now you see it, now you don’t

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).

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.