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Kadam A, Pantbalekundri N, Bhagawati J, Kumar S, Acharya S. Fat Embolism Due to Avascular Necrosis Leading to Acute Chest Syndrome in Sickle Cell Disease in a Youth: A Lethal Encounter. Cureus 2024; 16:e61043. [PMID: 38916022 PMCID: PMC11195325 DOI: 10.7759/cureus.61043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Accepted: 05/25/2024] [Indexed: 06/26/2024] Open
Abstract
Fat embolism syndrome (FES) is a rather uncommon presentation in sickle cell disease (SCD), most frequently happening in the context of long bone fractures following trauma. On the other hand, nontraumatic scenarios and nonorthopedic injuries have been documented to cause fat embolisms. This article describes the case of an 18-year-old male patient who had a known case of SCD (SS pattern). The patient complained of hip pain, and it was discovered that he had avascular necrosis of the right femoral head. The patient was started on opioid analgesics and started to respond to treatment; however, on the third day of admission, his condition deteriorated, oxygen saturation dropped, and the patient was shifted to the intensive care unit, where he was diagnosed with FES due to avascular necrosis. The patient's condition further deteriorated; he could not be saved and succumbed to death within one day. Very rarely has SCD with FES been reported in the literature.
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Affiliation(s)
- Abhinav Kadam
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, IND
| | - Nikhil Pantbalekundri
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, IND
| | - Jahnabi Bhagawati
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, IND
| | - Sunil Kumar
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, IND
| | - Sourya Acharya
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, IND
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2
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Thirugnanasambandam RP, Maraikayar FM, Liu M, Elbashir K, Muthu J. Fat Embolization Syndrome Secondary to Steroid Treatment in a Case of Sickle Cell Vaso-Occlusive Crisis. Case Rep Hematol 2023; 2023:5530870. [PMID: 37434655 PMCID: PMC10332925 DOI: 10.1155/2023/5530870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 06/13/2023] [Accepted: 06/25/2023] [Indexed: 07/13/2023] Open
Abstract
Fat embolization syndrome (FES) is often seen as a complication of fractures and has been known to cause respiratory failure, rashes of the skin, thrombocytopenia, and neurological damage. Nontraumatic FES is uncommon and occurs due to bone marrow necrosis. Vaso-occlusive crisis in sickle cell patients secondary to steroid therapy is a rare entity and not widely acknowledged. We report a case of FES secondary to steroid therapy administered for a patient with intractable migraine. FES is an uncommon yet serious complication that occurs due to bone marrow necrosis and is usually associated with increased mortality or damaging neurologic sequelae for the surviving patient. Our patient was initially admitted for intractable migraine and worked up to rule out any acute emergency conditions. She was then given steroids for her migraine which did not subside with the initial treatment. Her condition worsened, and she developed respiratory failure along with altered mental status requiring care in the intensive care unit (ICU). Imaging studies showed microhemorrhages throughout the cerebral hemispheres, brainstem, and cerebellum. The imaging of her lungs confirmed severe acute chest syndrome. The patient also had hepatocellular and renal injuries indicative of multiorgan failure. The patient was treated with a red cell exchange transfusion (RBCx) leading to an almost complete recovery in a few days. The patient, however, had residual neurological sequelae with the presence of numb chin syndrome (NCS). This report thus highlights the need to recognize potential multiorgan failure secondary to steroid treatment and the importance of initiating treatment with red cell exchange transfusions to decrease the risk of such complications secondary to steroids.
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Affiliation(s)
| | | | - Marie Liu
- Medical Student, SUNY Downstate Medical Center, Brooklyn, NY 11203, USA
| | - Khalid Elbashir
- Department of Adult Sickle Cell Practice, NYC Health + Hospitals/Kings County, Brooklyn, NY 11203, USA
| | - John Muthu
- Department of Adult Sickle Cell Practice, NYC Health + Hospitals/Kings County, Brooklyn, NY 11203, USA
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3
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Siniard RC, Gangaraju R, May JE, Marques MB. Challenges in the diagnosis of thrombotic thrombocytopenic purpura. Expert Rev Hematol 2023; 16:861-869. [PMID: 37767808 DOI: 10.1080/17474086.2023.2265058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 09/26/2023] [Indexed: 09/29/2023]
Abstract
INTRODUCTION Immune-mediated TTP (iTTP) is a rare condition without pathognomonic signs and symptoms. For this reason, the diagnosis of iTTP may be delayed or even missed, with potentially catastrophic consequences. AREAS COVERED The authors performed an extensive literature review on the diagnosis of iTTP and its challenges combined with their own experience in a referral center for patients with iTTP. EXPERT OPINION Although a definitive diagnosis of iTTP depends on the ADAMTS13 activity result, timely testing is rarely available at many centers to which patients present. If less complex tests were to become available, they would decrease the chances of late and/or missed diagnoses of iTTP throughout the world. While clinical scores to estimate the likelihood of iTTP exist, they are not well known, and can be misleading if used in the wrong context. Furthermore, the three scoring systems (PLASMIC, Bentley, and French) only moderately correlate with each other, which further complicates the landscape. The existence of these scores and how they should be used in practice is but one opportunity that can be seized through more robust programs to educate nonspecialist clinicians on how to recognize and treat patients with iTTP.
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Affiliation(s)
- Rance C Siniard
- Department of Pathology, Division of Laboratory Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Radhika Gangaraju
- Department of Medicine, Division of Hematology Oncology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jori E May
- Department of Medicine, Division of Hematology Oncology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Marisa B Marques
- Department of Pathology, Division of Laboratory Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Guo P, Rao T, Han W, Liang L, Ji H, Liu H, Lu Q. Use of VA-ECMO successfully rescued a trauma patient with fat embolism syndrome complicated with acute heart failure and acute respiratory distress syndrome. World J Emerg Med 2023; 14:332-334. [PMID: 37425078 PMCID: PMC10323504 DOI: 10.5847/wjem.j.1920-8642.2023.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 03/03/2023] [Indexed: 07/11/2023] Open
Affiliation(s)
- Pengchao Guo
- Emergency Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Taiwen Rao
- Emergency Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Wen Han
- Emergency Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Licai Liang
- Emergency Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Hongjue Ji
- Emergency Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Hong Liu
- Emergency Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Qin Lu
- Emergency Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
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Tsitsikas DA, Mihalca D, Hall J, May JE, Gangaraju R, Marques MB, Scully M. Pitfalls in Diagnosing Thrombotic Thrombocytopenic Purpura in Sickle Cell Disease. J Clin Med 2022; 11:jcm11226676. [PMID: 36431152 PMCID: PMC9696110 DOI: 10.3390/jcm11226676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 11/13/2022] Open
Abstract
Thrombotic thrombocytopenia purpura is characterised by microangiopathic haemolytic anaemia and red cell fragmentation on the peripheral smear, neurological involvement and thrombocytopenia. Diagnosis in the context of sickle cell disease can be challenging due to the inherent haemolytic state and the multitude of other associated complications of the latter. Specifically, fat embolism syndrome characterised by respiratory failure, neurological impairment and thrombocytopenia can be misdiagnosed this way. Confirmation of a diagnosis of thrombotic thrombocytopenic purpura requires demonstration of very low levels (<10%) of the metalloproteinase ADAMTS13 which in fat embolism syndrome is normal. Existing scoring systems used to estimate the pre-test probability for thrombotic thrombocytopenic purpura cannot be applied in patients with sickle cell disease due to the chronic underlying haemolysis. Here, we analyse the diagnostic approach in published cases of thrombotic thrombocytopenic purpura affecting patients with sickle-cell disease. The vast majority of cases were characterised by severe respiratory failure before any other manifestation, a feature of fat embolism syndrome but not of thrombotic thrombocytopenic purpura, and all received red cell transfusion prior to receiving therapeutic plasma exchange. Despite the potential overestimation of the pre-test probability using the existing scoring systems, a large number of cases still scored low. There were no cases with documented low ADAMTS13. In the majority this was not tested, while in the 3 cases that ADAMTS13 was tested, levels were normal. Our review suggests that due to many overlapping clinical and laboratory features thrombotic thrombocytopenic purpura may be erroneously diagnosed in sickle cell disease instead of other complications such as fat embolism syndrome and confirmation with ADAMTS13 testing is essential.
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Affiliation(s)
| | - Diana Mihalca
- Homerton Healthcare NHS Foundation Trust, London E9 6SR, UK
| | - John Hall
- Homerton Healthcare NHS Foundation Trust, London E9 6SR, UK
| | - Jori E. May
- Department of Pathology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Radhika Gangaraju
- Department of Pathology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Marisa B. Marques
- Department of Pathology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Marie Scully
- University College Hospital, 235 Euston Road, Fitzrovia, London NW1 2BU, UK
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Zheng XL. The standard of care for immune thrombotic thrombocytopenic purpura today. J Thromb Haemost 2021; 19:1864-1871. [PMID: 34060225 PMCID: PMC8324529 DOI: 10.1111/jth.15406] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 04/30/2021] [Accepted: 05/20/2021] [Indexed: 12/20/2022]
Abstract
Targeted therapy of immune thrombotic thrombocytopenic purpura (iTTP) requires acurate and prompt diagnosis and differentiation from complement-mediated hemolytic uremic syndrome and other causes of thrombotic microangiopathy. ADAMTS-13 (A Disintegrin And Metalloprotease with ThromboSpondin-1 Domain, member 13) evaluation (activity and inhibitors or anti-ADAMTS-13 IgG) is the key for diagnosis and further management of patients with suspected iTTP during acute episode and in clinical response or remission. Clinical trial results and real-world data have demonstrated the efficacy and safety of the triple therapy consisting of therapeutic plasma exchange, caplacizumab, and immunosuppressives (e.g., corticosteroids and rituximab) for acute iTTP. Such a therapeutic strategy has significantly accelerated the normalization of platelet counts, decreased the length of stays in the intensive care unit and the hospital, but most importantly reduced the mortality rate. The present review highlights some of the important advancements for the diagnosis and management of iTTP and proposes triple therapy as the standard of care for acute iTTP today.
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Affiliation(s)
- X Long Zheng
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
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Sangani V, Pokal M, Balla M, Merugu GP, Khokher W, Gayam V, Konala VM. Fat Embolism Syndrome in Sickle Cell β-Thalassemia Patient With Osteonecrosis: An Uncommon Presentation in a Young Adult. J Investig Med High Impact Case Rep 2021; 9:23247096211012266. [PMID: 34008428 PMCID: PMC8138282 DOI: 10.1177/23247096211012266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Fat embolism syndrome is a relatively infrequent presentation in sickle cell
thalassemia patients. It most commonly occurs in long bone fractures in the
setting of trauma. However, nonorthopedic trauma and nontraumatic cases have
been reported to contribute to fat embolism. The fat embolic syndrome is an
underdiagnosed, life-threatening, and debilitating complication of
sickle-β-thalassemia–related hemoglobinopathies. It is primarily seen in milder
versions of sickle cell disease, including HbSC and sickle cell β-thalassemia,
with the mild prior clinical course without complications; hence, diagnosis can
be easily missed. Pathogenesis of fat embolic syndrome is a combination of
mechanical obstruction from fat globules released into systemic circulation at
the time of bone marrow necrosis and direct tissue toxicity from fatty acids and
inflammatory cytokines released from fat globules. Prompt diagnosis and early
initiation of treatment can reduce morbidity and mortality and result in better
outcomes and prognosis. Red cell exchange transfusion is the mainstay of therapy
with mortality benefits. Overall mortality and neurological sequelae continue to
be high despite increased red cell exchange transfusion in the last few years.
In this article, we discussed a case of a 34-year-old male patient with a
history of sickle cell thalassemia and avascular necrosis of the hip, who
presented with fever, hypoxia, encephalopathy, and generalized body aches, found
to have thrombocytopenia and punctate lesions on magnetic resonance imaging
brain, which led to the diagnosis of the fat embolism syndrome. Only a few
sickle cell β-thalassemia with fat embolic syndrome cases have been
reported.
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Affiliation(s)
| | | | - Mamtha Balla
- University of Toledo, Toledo, OH, USA.,Promedica Toledo Hospital, Toledo, OH, USA
| | | | | | - Vijay Gayam
- Interfaith Medical Center, Brooklyn, NY, USA
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8
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Tsitsikas DA, Bristowe J, Abukar J. Fat Embolism Syndrome in Sickle Cell Disease. J Clin Med 2020; 9:jcm9113601. [PMID: 33171683 PMCID: PMC7695297 DOI: 10.3390/jcm9113601] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 11/05/2020] [Accepted: 11/07/2020] [Indexed: 12/31/2022] Open
Abstract
Fat embolism syndrome is a devastating complication of sickle cell disease resulting from extensive bone marrow necrosis and associated with high mortality rates, while survivors often suffer severe neurological sequelae. Despite that, the syndrome remains under-recognised and under-diagnosed. Paradoxically, it affects exclusively patients with mild forms of sickle cell disease, predominantly HbSC and HbSβ+. A significant number of cases occur in the context of human parvovirus B19 infection. We provide here a brief summary of the existing literature and describe our experience treating 8 patients in our institution. One patient had HbSS, 6 HbSC and 1 HbSβ+. All patients developed type I respiratory failure and neurological involvement either at presentation or within the first 72 h. The most striking laboratory abnormality was a 100-fold increase of the serum ferritin from baseline. Seven patients received emergency red cell exchange and 1 simple transfusion. Two patients (25%) died, 2 patients (25%) suffered severe neurological impairment and 1 (12%) mild neurological impairment on discharge, while 3 (38%) patients made a complete recovery. With long-term follow-up, 1 patient with severe neurological impairment and one patient with mild neurological impairment made dramatic improvements, making the long-term complete recovery or near complete recovery rate 63%. Immediate red cell exchange transfusion can be lifesaving and should be instituted as soon as the syndrome is suspected. However, as the outcomes remain unsatisfactory despite the increasing use of red cell exchange, we suggest additional therapeutic measures such as therapeutic plasma exchange and pre-emptive transfusion for high risk patients.
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Affiliation(s)
- Dimitris A. Tsitsikas
- Haemoglobinopathy Service, Department of Haematology, Homerton University Hospital NHS Foundation Trust, London E9 6SR, UK;
- Correspondence:
| | - Jessica Bristowe
- Research and Innovation Department, Homerton University Hospital NHS Foundation Trust, London E9 6SR, UK;
| | - Jibril Abukar
- Haemoglobinopathy Service, Department of Haematology, Homerton University Hospital NHS Foundation Trust, London E9 6SR, UK;
- School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth PO1 2UP, UK
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Tsitsikas DA, May JE, Gangaraju R, Abukar J, Amos RJ, Marques MB. Revisiting fat embolism in sickle syndromes: diagnostic and emergency therapeutic measures. Br J Haematol 2019; 186:e112-e115. [PMID: 31044433 DOI: 10.1111/bjh.15941] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Dimitris A Tsitsikas
- Haemoglobinopathy Service, Department of Haematology, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Jori E May
- Division of Hematology-Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Radhika Gangaraju
- Division of Hematology-Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jibril Abukar
- Haemoglobinopathy Service, Department of Haematology, Homerton University Hospital NHS Foundation Trust, London, UK.,University of Portsmouth, Portsmouth, UK
| | - Roger J Amos
- Haemoglobinopathy Service, Department of Haematology, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Marisa B Marques
- Division of Laboratory Medicine, Department of Pathology, University of Alabama at Birmingham, Birmingham, AL, USA
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