Splenic infarction, splenic sequestration, and functional hyposplenism in hemoglobin S-C disease

Splenic sequestration crisis as an index manifestation of heterozygous hemoglobinopathy in an adult

Sickle β⁺-thalassemia rarely manifests with acute splenic sequestration crisis in adults. We report a case of a 20-year-old female who presented with fever and left upper quadrant abdominal pain. Laboratory studies revealed hemolytic anemia. Tests for autoimmune hemolysis and hemolytic diseases were negative except for Hemoglobin (Hb) electrophoresis, which revealed sickle cell trait (Hb AS). Infectious workup was unremarkable. Computed tomography scan of the abdomen showed marked splenomegaly. The patient received blood transfusions and empiric antibiotics with no improvement; thus, splenectomy was performed. Pathology specimen revealed peripheral serpiginous infarcts alternating with surrounding acute inflammation and small capillaries plugged with sickle cell shaped red blood cells consistent with splenic sequestration. DNA test later revealed beta-globin mutations consistent with sickle cell-beta⁺ thalassemia. Post-splenectomy, there was a gradual improvement in her clinical symptoms with concomitant rise in Hb to 10.6 g/dl at discharge.

Acute splenic sequestration crisis in adults with hemoglobin S-C disease: a report of nine cases

Acute splenic sequestration crisis (ASSC) is a potentially life-threatening complication and one of the leading causes of death in children with sickle cell disease. It is rarely reported in adults with hemoglobin S-C disease and its natural history in these patients has not been well studied. We describe here the clinicopathological features of ASSC in nine adults with hemoglobin S-C disease treated between 1972 and 2000 and followed for a mean period of 9 years (range 0-21 years). ASSC was characterized by acute left upper quadrant abdominal pain, splenomegaly, fever, and a rapid decrease in hematocrit with active erythropoiesis. The hemoglobin decreased by a mean of 4.8 g/dl from the steady state value (range 3.0 to 6.7 g/dl) during ASSC. Two patients failed to respond to transfusion of packed erythrocytes and required urgent splenectomy. There was one fatality-a 76-year-old woman, who died 36 h after admission. There was no recurrence of ASSC in five patients followed for 2, 3, 16, 18, and 21 years, respectively. ASSC in adults is a serious and occasionally, fatal complication of hemoglobin S-C disease. Patients with hemoglobin S-C disease may remain at risk of ASSC into their eighth decade.

Acute Splenic Sequestration Crisis Resembling Sepsis in an Adult with Hemoglobin SC Disease

Acute splenic sequestration crisis (ASSC) is a common complication of sickle cell anemia in children. ASSC is generally not seen in adults with the SS genotype but occasionally can be seen in adults with the SC genotype. We present a case of fulminant ASSC in an adult with hemoglobin SC who developed high fever, intense abdominal pain, leukocytosis, and jaundice.

The paradox of hemoglobin SC disease

Homozygous HbC gene results only in mild hemolytic anemia. In HbSC disease red cells contain equal levels of HbS and HbC. It is a paradox that HbSC exhibit a moderately severe phenotype in spite of being a mixture of HbS trait and HbC trait, neither of which has significant pathology. Why does the combination of these two Hbs result in a serious disease? The short answer is that HbC enhances, by dehydrating the SC red cell, the pathogenic properties of HbS, resulting in a clinically significant disorder, but somewhat milder that sickle cell anemia (SCA). Nevertheless, retinnitis proliferans, osteonecrosis, and acute chest syndrome have equal or higher incidence in HbSC disease compared to SCA. This pathogenic trick is accomplished by HbC inducing, by mechanisms not fully understood, an increase in the activity of K:Cl cotransport that induces the lost of K(+) and consequently of intracellular water. This event creates a sufficient increase of MCHC, so that the lower levels of HbS found in SC red cells can polymerize rapidly and effectively. This situation offers a unique opportunity: if we could inhibit the effect of HbC on K(+) transport we can cure the disease.

Palpable splenomegaly in children with haemoglobin SC disease: haematological and clinical manifestations

This study aimed to investigate the prevalence of palpable splenomegaly in children with haemoglobin SC (Hb SC) disease, and to determine the haematological and clinical manifestations of splenomegaly in this patient population. We performed a retrospective chart review of 100 patients with Hb SC over 2 years of age followed by the Duke University Paediatric Sickle Cell Program with serial physical examinations and laboratory measurements. Palpable splenomegaly was present in 34% of patients and was more common in males (P = 0.029). Children with splenomegaly had a significantly lower average haemoglobin concentration (10.3 vs. 10.8 g/dl, P = 0.011) and lower platelet count (237 vs. 314 x 109/l, P < 0.001) than those without splenomegaly. Children with measurements both before and after the onset of splenomegaly had a significant decrease in the platelet count (279 vs. 216 x 109/l, P < 0.001) and white blood cell count (9.1 vs. 7.9 x 109/l, P = 0.04) after splenomegaly was identified. Clinical complications included acute splenic sequestration in 12% of children (median age 5.4 years), and hypersplenism with chronic thrombocytopenia in another 10% of patients (median age 10.6 years). Splenomegaly is a common physical finding in children with Hb SC disease and is often associated with mild cytopenias. Clinical complications of splenomegaly include acute splenic sequestration in younger patients and hypersplenism with chronic thrombocytopenia in older children.

Acute splenic complications in children with sickle cell-hemoglobin C disease

OBJECTIVE

To determine the frequency and severity of acute splenic complications in children and adolescents with sickle cell (SC) hemoglobin C disease.

METHODS

The medical records of 271 patients with SC disease seen at our center were reviewed to evaluate the incidence and severity of acute complications involving the spleen.

RESULTS

Sixteen (6%) children had acute splenic complications. Thirteen (5%) had 16 episodes of acute splenic sequestration (ASSC), with the initial event occurring at a mean age of 8.9 years (range, 2 to 17 years). Splenomegaly had been noted before the initial event in 6 (46%) of the 13 cases, and 3 (23%) had a history of painful splenic infarction. Two young children (aged 4 and 6 years) had a hemoglobin value less than 2 gm/dl, one without history of splenic enlargement. Three (23%) children had a second episode of ASSC. Three additional patients had a history of acute painful splenic infarction, two of whom also had splenic hemorrhage. Eight (3%) of the 271 children required splenectomy (1 after the initial episode of ASSC, 3 after a second episode of ASSC, 2 as a result of pain accompanying chronic infarction and ASSC, and 2 because of splenic hemorrhage). No deaths resulted from ASSC.

CONCLUSIONS

We conclude that (1) acute splenic complications in children and adolescents with SC disease are relatively uncommon, (2) most episodes of ASSC occur in preadolescents, (3) ASSC can be life threatening, even in younger children, and (4) prior splenomegaly is not a good predictor of ASSC. Thus it is vital that the parents of all children with SC disease be instructed to palpate their child's spleen regularly.

Case report: splenic sequestration and multiorgan failure as the presenting manifestation of hemoglobin SC disease

Acute splenic sequestration, a well recognized complication of the various sickle cell syndromes, is characterized by increasing splenomegaly and a sudden fall in hemoglobin concentration. In this article, the authors describe a 21-year-old woman with previously undiagnosed hemoglobin SC disease whose initial presentation was that of acute, severe splenic sequestration. Despite the severity of her illness, prompt diagnosis and appropriate therapy led to a complete recovery. The splenic sequestration in this case was apparently exacerbated by a recent hepatitis B infection. To date, this presentation of hemoglobin SC disease has not been described in the medical literature.

Splenic sequestration associated with sickle cell trait and hereditary spherocytosis

Coexistence of sickle cell trait and hereditary spherocytosis (HS) is unusual, and only 16 cases have been reported in the literature. These patients have the same clinical and hematological features as individuals having HS alone. We report a serious complication, acute splenic sequestration crisis (ASSC), occurring in two patients with sickle cell trait and HS. One patient experienced four episodes of ASSC during an 11-year span, while the other had two episodes of this complication during a 4-year period. Red blood cell studies and membrane protein analysis confirmed the diagnosis of HS as a consequence of spectrin deficiency. Splenectomy resulted in marked clinical and hematological improvement in both patients. Histological examination of spleens following splenectomy confirmed that significant erythrostasis and sickling had indeed occurred. ASSC can occur in patients with coexistence of sickle cell trait and HS, and this potentially life-threatening complication should be considered in this condition.

A fatal case of acute splenic sequestration in a 53-year-old woman with sickle-hemoglobin C disease

Acute splenic sequestration crisis (ASSC) is a common complication in infants and young children with homozygous sickle cell disease, but it is infrequent in patients with sickle-hemoglobin C (SC) disease. When it does occur in such patients, it is often associated with exposure to high altitude, either by air travel or mountainous environment. Since 1970, only 15 cases of ASSC have been reported in patients with SC disease who were not exposed to a high altitude. Nine of these were children and adolescents aged 11 to 18 years, while six were adults aged 21 to 44 years. A review of these cases shows only two fatalities from ASSC: a 12-year-old West Indian girl living in England and a 13-year-old black girl in the United States. In this report, we describe the sudden death from ASSC of a 53-year-old black woman with SC disease at low altitude. To our knowledge, death from ASSC has not been previously reported in an adult patient with SC disease.

Case report: splenic infarction and acute splenic sequestration in adults with hemoglobin SC disease

While acute splenic sequestration and splenic infarction are commonly observed in infants and young children with sickle cell anemia, they are rarely experienced by adult hemoglobin S homozygotes because the recurrent splenic infarction that takes place during childhood is typically followed by scarring, atrophy, and splenic fibrosis. Both acute splenic sequestration and splenic infarction do remain relatively common in adults with the other sickle hemoglobinopathies. These episodes are almost certainly a consequence of the persistently enlarged and distensible spleens that often remain present in these conditions. In this report, the authors describe two adult patients with hemoglobin SC disease: one who developed acute splenic sequestration and one with splenic infarction. In neither case was there a history of recent air travel or exposure to altitude. The clinical course of these two syndromes is presented, and the hematologic, radiologic, and pathologic manifestations are discussed. Because they can sometimes be difficult to distinguish from one another, and because a failure to identify acute splenic sequestration can be catastrophic, these two entities must be included in the differential diagnosis for any hemoglobin SC patient who present with an unexplained fall in hemoglobin, left upper quadrant pain, unexplained fever, or symptomatic splenomegaly.

Splenic infarction at low altitude in a child with hemoglobin S-C disease

We describe a 15-year-old black boy with hemoglobin S-C disease living in Atlanta (altitude 1,034 ft), with no prior history of aircraft or mountain travel, who developed splenic infarction. The clinical picture was characterized by severe left upper quadrant abdominal pain, fever, splenomegaly, and hematologic and scintigraphic evidence of functional asplenia. The diagnosis was suggested by liver/spleen scintigraphy and further confirmed by ultrasonography and computerized tomography (CT) of the spleen. Treatment consisted of analgesics, intravenous fluids, and short-term antibiotic therapy. The child recovered without sequelae.