1
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Habibi A, Pirenne F. Les anémies aiguës et la stratégie transfusionnelle chez les drépanocytaires adultes. Rev Med Interne 2023; 44:4S12-4S17. [PMID: 38049241 DOI: 10.1016/s0248-8663(23)01304-8] [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] [Indexed: 12/06/2023]
Abstract
Worsening of anemia is very common in sickle cell disease. It is important to investigate specific complications related to sickle cell disease but also other causes of anemia in general. Transfusions or exchange transfusions are major therapeutic options and are frequently used for acute complications of sickle cell disease but also for primary and secondary prevention of some of the chronic complications. The transfusion strategy has been modified since the awareness of post-transfusion hemolysis by taking into account the transfusion risk score. A strong collaboration between the patient's expert center, the Blood center and the patient's hospitalization unit is required to make decisions. © 2023 Société nationale française de médecine interne (SNFMI). Published by Elsevier Masson SAS. All rights reserved.
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Affiliation(s)
- A Habibi
- Centre de référence des syndromes drépanocytaires majeurs, unité des maladies génétiques du globule rouge, CHU Henri-Mondor, AP-HP, Créteil, France; INSERM-U955, institut Mondor, université Paris-Est Créteil, team 2 Transfusion et maladies du globule rouge, laboratoire d´excellence GR-Ex, Créteil, France.
| | - F Pirenne
- INSERM-U955, institut Mondor, université Paris-Est Créteil, team 2 Transfusion et maladies du globule rouge, laboratoire d´excellence GR-Ex, Créteil, France; Établissement français du sang Île-de-France, Paris, France
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2
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Alzayadneh MA, Alsherbini KA. A Rare Case of Progressive Encephalopathy in a Sickle Cell Trait Patient: A Case Report. Cureus 2023; 15:e45936. [PMID: 37766778 PMCID: PMC10520993 DOI: 10.7759/cureus.45936] [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] [Accepted: 09/25/2023] [Indexed: 09/29/2023] Open
Abstract
Fat embolism syndrome (FES) is one of the underdiagnosed and underrecognized complications that can happen in multiple medical and surgical conditions. FES can manifest in a broad spectrum of signs and symptoms and affect multiple organ systems in the human body. One of the most commonly involved is the central nervous system (CNS), mainly the brain, which can be involved in different ways, and the presenting symptoms can vary in type and severity. One of the most common causes of FES is trauma, mainly a long bone fracture or any orthopedic injury. However, one of the rare causes of FES is sickle cell disease (SCD) and thalassemia. Generalized and vague presenting symptoms, the rarity of FES, and the absence of well-defined diagnostic criteria make it a challenging diagnosis for healthcare practitioners. FES diagnosis is usually made after having a high index of suspicion in patients with underlying risk factors that can precipitate and contribute to the pathophysiology of FES. Moreover, the diagnosis is usually reached after excluding other more common and treatable conditions.
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Affiliation(s)
| | - Khalid A Alsherbini
- Neurology/Neurocritical Care, University of Tennessee Health Science Center (UTHSC), Memphis, 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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4
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Farid M, Zohny E, Ismail A, Ateya M, Abdel-Razek A, Hamed N, Elmarakby A, Hassanin A, Ismail A, Mansour O, Roshdy H, Ahmed Y, Ismail M, Amin HAA. Bone marrow embolism: should it result from traumatic bone lesions? A histopathological human autopsy study. Forensic Sci Med Pathol 2023:10.1007/s12024-023-00609-2. [PMID: 37133760 DOI: 10.1007/s12024-023-00609-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2023] [Indexed: 05/04/2023]
Abstract
Bone marrow embolism (BME) is likely a consequence of fractures in which pulmonary vessels are the most affected. However, some cases of BME were reported in the absence of trauma. Thus, a traumatic injury might not be necessary for developing BME. This study discusses BME cases in patients without signs of fractures or blunt trauma. The discussion addresses various possible mechanisms for the appearance of BME. Options include cancer in which bone marrow metastasis is a suggestive cause. Another proposal is the chemical theory where bone marrow fats are released via lipoprotein lipase in a pro-inflammatory state, resulting in vascular/pulmonary obstruction. Other cases discussed in this study are hypovolemic shock and drug-abuse related BME. All autopsy cases with BME were included regardless of the cause of death for a period of 2 years. Autopsies involved complete dissection with the macroscopic evaluation of the affected organs, including the heart, lungs, and brain. Tissues were also prepared for microscopic examination. Of the 11 cases, eight showed non-traumatic BME (72%). These findings conflict with theories in the literature that BME most commonly occurs after fractures or trauma. One of the eight cases exhibited mucinous carcinoma; one is presented with hepatocellular carcinoma; and two cases showed severe congestion. Lastly, one case was found to be associated with each of the following conditions: liposuction, drug abuse, pulmonary hypertension, and heart failure. Each case suggests a different pathophysiology for developing BME, yet the exact mechanisms are not fully understood. Further study of non-traumatic associated BME is recommended.
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Affiliation(s)
- Maha Farid
- Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Helwan University, Cairo, Egypt.
| | - Esraa Zohny
- Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Alaa Ismail
- Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Mariem Ateya
- Faculty of Medicine, Helwan University, Cairo, Egypt
| | | | - Nermien Hamed
- Faculty of Medicine, Helwan University, Cairo, Egypt
| | | | - Arwa Hassanin
- Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Ahmed Ismail
- Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Omar Mansour
- Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Hossam Roshdy
- Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Yehia Ahmed
- Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Mariam Ismail
- Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Hebat Allah A Amin
- Department of Pathology, Faculty of Medicine, Helwan University, Cairo, Egypt
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5
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Tsitsikas DA, Rowe S, Bosch A, Hui C, Sadasivam N, Palaskas NJ, Pancham S, Rizvi S, Taylor J, Greaves P, Glenthøj A, Hoffmann M, Drasar E, Eleftheriou P. Addition of plasma exchange to red cell exchange improves outcomes of fat embolism syndrome in sickle cell disease. Br J Haematol 2023; 200:e50-e52. [PMID: 36594271 DOI: 10.1111/bjh.18638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 12/17/2022] [Accepted: 12/21/2022] [Indexed: 01/04/2023]
Affiliation(s)
| | - Susan Rowe
- Homerton University Hospital NHS Foundation Trust, London, UK
| | | | - Caitlyn Hui
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Nicolaos J Palaskas
- David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Shivan Pancham
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Syed Rizvi
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | | | - Andreas Glenthøj
- Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | | | - Emma Drasar
- University College London hospital, London, UK
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6
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Samaee S, Samaee S, Mihalca D, Fitzgerald L, Ahmed A, Hall J, Tsitsikas DA. Mortality Rates and autopsy findings in fat embolism syndrome complicating sickle cell disease. J Clin Pathol 2023:jcp-2023-208763. [PMID: 36849230 DOI: 10.1136/jcp-2023-208763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 02/02/2023] [Indexed: 03/01/2023]
Abstract
Fat embolism syndrome is a rare but underdiagnosed complication of sickle cell disease associated with high morbidity and mortality. It affects predominantly patients with a previously mild course of their illness and those of non-SS genotypes while there is possibly an association with infection with human parvovirus B19 (HPV B19). Here, we present the mortality rates and autopsy findings of all reported cases to date. A systematic review has revealed 99 published cases in the world literature with a mortality rate of 46%. Mortality varied greatly according to the time of reported cases with no survivors in the 1940s, 1950s or 1960s and no deaths since 2020. 35% of cases had previously undiagnosed sickle cell disease and the latter was only identified at autopsy after developing fat embolism with a fatal outcome. 20% of cases reported after 1986 tested positive for HPV B19 with an associated mortality of 63% whereas in cases that have not documented HPV B19 infection the mortality was 32%. The organs most often staining positive for fat were the kidneys, lungs, brain and heart whereas ectopic haematopoietic tissue was found in 45% of the examined lung specimens.
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Affiliation(s)
- Sayna Samaee
- Haematology, Homerton Healthcare NHS Foundation Trust, London, UK
| | - Sepideh Samaee
- Haematology, Homerton Healthcare NHS Foundation Trust, London, UK
| | - Diana Mihalca
- Haematology, Homerton Healthcare NHS Foundation Trust, London, UK
| | | | - Adeel Ahmed
- Haematology, Homerton Healthcare NHS Foundation Trust, London, UK
| | - John Hall
- Haematology, Homerton Healthcare NHS Foundation Trust, London, UK
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7
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Rizvi S, Khakwani M, Pancham S, Tsitsikas D, Rudzki Z, Hassan‐Smith G, Bowen M, Wright C, Park D. Bone marrow necrosis and fat embolism syndrome in sickle cell disease during COVID-19 infection treated successfully with sequential red cell and plasma exchange. EJHAEM 2022; 4:JHA2621. [PMID: 36718354 PMCID: PMC9877825 DOI: 10.1002/jha2.621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 11/09/2022] [Accepted: 11/14/2022] [Indexed: 12/23/2022]
Abstract
Fat embolism syndrome (FES) is a rare life-threatening condition that is particularly seen in milder forms of sickle cell disease (SCD). Widespread systemic fat emboli are generated in the context of extensive bone marrow necrosis. Multi-organ failure with a high morbidity and mortality may quickly develop. Infection with Parvovirus B19 is a common precipitant. Here, the authors report the case of a 35-year-old Afro-Caribbean man with HbSC disease who presented with FES having tested positive for SARS-COV-2. He rapidly became critically ill and required admission to the intensive care unit for organ support. He was treated with red cell exchange and plasma exchange and made a good recovery to leave hospital at week 7.
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Affiliation(s)
- Syed Rizvi
- Department of Acute Internal MedicineUniversity Hospitals Birmingham (UHB) NHS Foundation TrustBirminghamUK
| | - Muhammad Khakwani
- Department of HaematologyUniversity Hospitals Birmingham (UHB) NHS Foundation TrustBirminghamUK
| | - Shivan Pancham
- Department of HaematologySandwell and West Birmingham Hospitals (SWBH) NHS TrustBirminghamUK
| | - Dimitris Tsitsikas
- Department of HaematologyHomerton University Hospital (HUH) NHS Foundation TrustLondonUK
| | - Zbigniew Rudzki
- Department of HistopathologyUniversity Hospitals Birmingham (UHB) NHS Foundation TrustBirminghamUK
| | - Ghaniah Hassan‐Smith
- Department of NeurologyUniversity Hospitals Birmingham (UHB) NHS Foundation TrustBirminghamUK
| | - Michael Bowen
- Department of Neuro-radiologyUniversity Hospitals Birmingham (UHB) NHS Foundation TrustBirminghamUK
| | - Christine Wright
- Department of HaematologySandwell and West Birmingham Hospitals (SWBH) NHS TrustBirminghamUK
| | - Daniel Park
- Department of Respiratory and Critical Care MedicineUniversity Hospitals Birmingham (UHB) NHS Foundation TrustBirminghamUK
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8
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Runge A, Brazel D, Pakbaz Z. Stroke in sickle cell disease and the promise of recent disease modifying agents. J Neurol Sci 2022; 442:120412. [PMID: 36150233 DOI: 10.1016/j.jns.2022.120412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 09/01/2022] [Accepted: 09/04/2022] [Indexed: 10/31/2022]
Abstract
Sickle cell disease (SCD) is an inherited hemoglobinopathy affecting approximately 100,000 individuals in the United States. Cerebrovascular disease is among the most common and debilitating complications of SCA, with 53% experiencing silent cerebral infarct by age 30 and 3.8% experiencing overt stroke by age 40 years. This review highlights the burden of cerebrovascular disease in SCD, including both stroke and silent cerebral infarct (SCI). We then discuss the pathophysiology of stroke and cerebral fat embolism in the absence of a patent foramen ovale. This review also reveals that options for primary and secondary stroke prevention in SCD are still limited to hydroxyurea and blood transfusion, and that the role of aspirin and anticoagulation in SCD stroke has not been adequately studied. Limited data suggest that the novel disease-modifying agents for SCD management may improve renal dysfunction, leg ulcers, and lower the abnormally high TCD flow velocity. Further research is urgently needed to investigate their role in stroke prevention in SCD, as these novel agents target the main stroke contributors in SCD - hemolysis and vaso-occlusion. This literature review also explores the role of healthcare disparities in slowing progress in SCD management and research in the United States, highlighting the need for more investment in patient and clinician education, SCD management, and research.
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Affiliation(s)
- Ava Runge
- University of California Irvine School of Medicine, CA, USA
| | - Danielle Brazel
- University of California Irvine Medical Center, Department of Medicine, Orange California, CA, USA
| | - Zahra Pakbaz
- University of California Irvine School of Medicine, CA, USA; University of California Irvine Medical Center, Department of Medicine, Orange California, CA, USA; University of California Irvine Medical Center, Division of Hematology Oncology, CA, USA.
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9
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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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10
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Jain V, Remley W, Bunag C, Rodriguez E, Albayram MS, Wilson C, Patterson A, Bonnell G, Okun MS, Patel B. Clinical Reasoning: A Case of Acute Akinetic Mutism and Encephalopathy. Neurology 2022; 99:761-766. [PMID: 36008149 PMCID: PMC9620815 DOI: 10.1212/wnl.0000000000201207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 07/21/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Varun Jain
- From the Department of Neurology (V.J., C.B., E.R., C.W., A.P., G.B., M.S.O., B.P.), University of Florida, Gainesville; Lake Erie College of Osteopathic Medicine (W.R.), Bradenton, FL; and Department of Radiology (M.S.A.), University of Florida, Gainesville.
| | - William Remley
- From the Department of Neurology (V.J., C.B., E.R., C.W., A.P., G.B., M.S.O., B.P.), University of Florida, Gainesville; Lake Erie College of Osteopathic Medicine (W.R.), Bradenton, FL; and Department of Radiology (M.S.A.), University of Florida, Gainesville
| | - Cyra Bunag
- From the Department of Neurology (V.J., C.B., E.R., C.W., A.P., G.B., M.S.O., B.P.), University of Florida, Gainesville; Lake Erie College of Osteopathic Medicine (W.R.), Bradenton, FL; and Department of Radiology (M.S.A.), University of Florida, Gainesville
| | - Elsa Rodriguez
- From the Department of Neurology (V.J., C.B., E.R., C.W., A.P., G.B., M.S.O., B.P.), University of Florida, Gainesville; Lake Erie College of Osteopathic Medicine (W.R.), Bradenton, FL; and Department of Radiology (M.S.A.), University of Florida, Gainesville
| | - Mehmet S Albayram
- From the Department of Neurology (V.J., C.B., E.R., C.W., A.P., G.B., M.S.O., B.P.), University of Florida, Gainesville; Lake Erie College of Osteopathic Medicine (W.R.), Bradenton, FL; and Department of Radiology (M.S.A.), University of Florida, Gainesville
| | - Christina Wilson
- From the Department of Neurology (V.J., C.B., E.R., C.W., A.P., G.B., M.S.O., B.P.), University of Florida, Gainesville; Lake Erie College of Osteopathic Medicine (W.R.), Bradenton, FL; and Department of Radiology (M.S.A.), University of Florida, Gainesville
| | - Addie Patterson
- From the Department of Neurology (V.J., C.B., E.R., C.W., A.P., G.B., M.S.O., B.P.), University of Florida, Gainesville; Lake Erie College of Osteopathic Medicine (W.R.), Bradenton, FL; and Department of Radiology (M.S.A.), University of Florida, Gainesville
| | - Gabriel Bonnell
- From the Department of Neurology (V.J., C.B., E.R., C.W., A.P., G.B., M.S.O., B.P.), University of Florida, Gainesville; Lake Erie College of Osteopathic Medicine (W.R.), Bradenton, FL; and Department of Radiology (M.S.A.), University of Florida, Gainesville
| | - Michael S Okun
- From the Department of Neurology (V.J., C.B., E.R., C.W., A.P., G.B., M.S.O., B.P.), University of Florida, Gainesville; Lake Erie College of Osteopathic Medicine (W.R.), Bradenton, FL; and Department of Radiology (M.S.A.), University of Florida, Gainesville
| | - Bhavana Patel
- From the Department of Neurology (V.J., C.B., E.R., C.W., A.P., G.B., M.S.O., B.P.), University of Florida, Gainesville; Lake Erie College of Osteopathic Medicine (W.R.), Bradenton, FL; and Department of Radiology (M.S.A.), University of Florida, Gainesville
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11
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Jacquot R, Gerfaud-Valentin M, Mekki Y, Billaud G, Jamilloux Y, Sève P. [Parvovirus B19 infections in adults]. Rev Med Interne 2022; 43:713-726. [PMID: 36088203 DOI: 10.1016/j.revmed.2022.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/29/2022] [Accepted: 08/21/2022] [Indexed: 12/11/2022]
Abstract
Acute Parvovirus B19 (PVB19) infection is responsible for erythema infectiosum in children and non-specific polyarthralgias in immunocompetent adults associated with skin lesions and rarer manifestations (hepatic, neurological, cardiac or nephrological). In immunocompromised patients, cytopenias are more frequent and in some cases, viremia persists and is responsible for PVB19 chronic infection. PVB19 is responsible for pure red cell aplasia during chronic hemolytic diseases. Acute PVB19 infection is a differential diagnosis of some autoimmune diseases and has been suspected to be a trigger for some autoimmune diseases because of its ability to promote the emergence of autoimmune markers. Mechanisms of molecular mimicry, induction of apoptosis and activation of enzymes have been demonstrated, explaining in part the production of autoantibodies during infection. However, the demonstration of a causal relationship in the triggering of autoimmune disease remains to be done. This review provides a synthesis of the PVB19 infection clinical data in adults with a particular focus on these links with autoimmunity.
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Affiliation(s)
- R Jacquot
- Service de médecine interne, hospices civils de Lyon, hôpital de la Croix-Rousse, 103, Grande-Rue de la Croix-Rousse, 69317 Lyon cedex 04, France; Université de Lyon, Lyon, France.
| | - M Gerfaud-Valentin
- Service de médecine interne, hospices civils de Lyon, hôpital de la Croix-Rousse, 103, Grande-Rue de la Croix-Rousse, 69317 Lyon cedex 04, France; Université de Lyon, Lyon, France
| | - Y Mekki
- Université de Lyon, Lyon, France
| | | | - Y Jamilloux
- Service de médecine interne, hospices civils de Lyon, hôpital de la Croix-Rousse, 103, Grande-Rue de la Croix-Rousse, 69317 Lyon cedex 04, France; Université de Lyon, Lyon, France
| | - P Sève
- Service de médecine interne, hospices civils de Lyon, hôpital de la Croix-Rousse, 103, Grande-Rue de la Croix-Rousse, 69317 Lyon cedex 04, France; Université de Lyon, Lyon, France; Université Claude-Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), Inserm U1290, Lyon, France; Laboratoire de virologie, hospices civils de Lyon, centre de biologie et de pathologie, hôpital de la Croix-Rousse, 103, Grande-Rue de la Croix-Rousse, 69317 Lyon cedex 04, France
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12
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Identifying and Treating Severe Bone Marrow Necrosis and Fat Embolism Syndrome in Pediatric Patients With Sickle Cell Disease: A Case Report. J Pediatr Hematol Oncol 2022; 44:e884-e887. [PMID: 35082243 DOI: 10.1097/mph.0000000000002399] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 12/06/2021] [Indexed: 11/25/2022]
Abstract
Fat embolism syndrome after bone marrow necrosis is an extremely rare complication in sickle cell disease associated with significant morbidity and mortality. A high index of suspicion is required for diagnosis. This case report will assist pediatric clinicians and hematologists to recognize this severe complication in patients with sickle cell disease and to promptly initiate treatment. Red flags include severe bone pain, respiratory distress, neurological impairment, decreasing platelet count, peripheral leukocyte left shift, elevated nucleated red blood cells, and significant elevation in plasma ferritin and lactate dehydrogenase. We report a pediatric patient who was diagnosed early, received urgent red cell exchange transfusion and plasma exchange, and ultimately survived this devastating complication.
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13
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Niazi MRK, Chukkalore D, Jahangir A, Sahra S, Macdougall K, Rehan M, Odaimi M. Management of acute chest syndrome in patients with sickle cell disease: a systematic review of randomized clinical trials. Expert Rev Hematol 2022; 15:547-558. [PMID: 35666654 DOI: 10.1080/17474086.2022.2085089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Acute chest syndrome (ACS) accounts for the highest mortality in Sickle cell disease patients. Early diagnosis and timely management of ACS results in better outcomes. However, the effectiveness of most treatment modalities for ACS management has not been established. AREAS COVERED To review the treatment modalities management protocols and highlight the effectiveness of each option a literature search was done. Randomized controlled trials that assessed the efficacy of different treatment modalities in ACS management in SCD patients were chosen and reviewed. EXPERT OPINION 11 randomized controlled trials were found that evaluated the efficacy of incentive spirometry, positive expiratory pressure device, intravenous dexamethasone, oral vs. intravenous morphine, inhaled nitric oxide, unfractionated heparin, and blood transfusion in the prevention or treatment of ACS. Although there are guidelines for ACS treatment, the available evidence is very limited to delineating the effectiveness of various interventions in ACS management. More high-quality studies and trials with a larger patient population can benefit this area to support the recommendations with stronger evidence.
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Affiliation(s)
- Muhammad Rafay Khan Niazi
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, New York, NY, USA
| | - Divya Chukkalore
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, New York, NY, USA
| | - Abdullah Jahangir
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, New York, NY, USA
| | - Syeda Sahra
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, New York, NY, USA
| | - Kira Macdougall
- Department of Hematology and Medical Oncology, Oklahoma University of Health and Science, Oklahoma, OK, USA
| | - Maryam Rehan
- Department of Hematology and Medical Oncology, Staten Island University Hospital/Northwell Health, New York, NY, USA
| | - Marcel Odaimi
- Department of Hematology and Medical Oncology, Staten Island University Hospital/Northwell Health, New York, NY, USA
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14
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Filippatou AG, Naveed M, Barry DP, Deboer SR, Haas CJ. Sickle cell disease and fat embolism: a rare complication of vaso-occlusive crisis. Pract Neurol 2022; 22:410-412. [PMID: 35450964 DOI: 10.1136/practneurol-2021-003166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2022] [Indexed: 11/04/2022]
Abstract
A 61-year-old woman was admitted to the hospital for management of a painful vaso-occlusive crisis. She had a history of sickle cell beta-thalassaemia and end-stage renal disease managed with intermittent haemodialysis. While hospitalised, she became lethargic and unresponsive and developed acute chest syndrome. Initial MR scan of brain, cerebrospinal fluid examination and continuous electroencephalogram were unremarkable, but subsequent MR scan of brain identified a right transverse venous sinus thrombosis and extensive supratentorial and infratentorial microhaemorrhages consistent with fat emboli. We; therefore, discuss a case of non-traumatic fat embolism syndrome, a rare complication of sickle cell disease.
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Affiliation(s)
| | - Muhammad Naveed
- Department of Internal Medicine, MedStar Health, Baltimore, Maryland, USA
| | - Daniel P Barry
- Department of Internal Medicine, MedStar Health, Baltimore, Maryland, USA
| | - Scott R Deboer
- Department of Neurology, MedStar Health, Baltimore, Maryland, USA
| | - Christopher J Haas
- Department of Internal Medicine, MedStar Health, Baltimore, Maryland, USA
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15
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Klings ES, Steinberg MH. Acute chest syndrome of sickle cell disease: genetics, risk factors, prognosis and management. Expert Rev Hematol 2022; 15:117-125. [PMID: 35143368 DOI: 10.1080/17474086.2022.2041410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
IntroductionSickle cell disease, one of the world's most prevalent Mendelian disorders, is a chronic hemolytic anemia punctuated by acute vasoocclusive events. Both hemolysis and vasoocclusion lead to irreversible organ damage and failure. Among the many sub-phenotypes of sickle cell disease is the acute chest syndrome (ACS) characterized by combinations of chest pain, cough, dyspnea, fever, abnormal lung exam, leukocytosis, hypoxia, and new radiographic opacities. ACS is a major cause of morbidity and mortality.Area coveredWe briefly review the diagnosis, epidemiology, etiology, and current treatments for ACS and focus on understanding and estimating the risks for developing this complication, how prognosis and outcomes might be improved and the genetic elements that might impact the risk of ACS.Expert opinionThe clinical heterogeneity of ACS has hindered our understanding of risk stratification. Lacking controlled clinical trials most treatment is based on expert opinion. Fetal hemoglobin levels and coexistent α thalassemia affect the incidence of ACS; other genetic associations are tenuous. Transfusions, whose use not innocuous, should be targeted to the severity and likelihood of ACS progression. Stable, non-hypoxic patients with favorable hematologic and radiographic findings usually do not need transfusion; severe progressive ACS is best managed with exchange transfusion.
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Affiliation(s)
- Elizabeth S Klings
- Sections of Pulmonary, Allergy, Sleep and Critical Care Medicine, Boston University School of Medicine, Boston, USA
| | - Martin H Steinberg
- Hematology and Medical Oncology, Center of Excellence for Sickle Cell Disease, Boston University School of Medicine and Boston Medical Center, Boston, USA
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16
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Melvin RG, Liederman Z, Arya S, Rotin L, Lee CM. A Case of Fat Embolism Syndrome with Cerebral Involvement in Sickle Cell Anemia. Hemoglobin 2021; 45:269-273. [PMID: 34749584 DOI: 10.1080/03630269.2021.1990081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Fat embolism syndrome (FES) is a rare condition that can occur as a complication of sickle cell disease. We describe a case of a patient with sickle cell disease (homozygous Hb S or HBB: c.20A>T) presenting with initial signs and symptoms consistent with a vaso-occlusive crisis (VOC). Within 24 hours, the patient developed evidence of coagulopathy, multi organ failure and a reduced level of consciousness (LOC) prompting intubation. A diagnosis of FES was made on the basis of the patient's clinical presentation, in conjunction with magnetic resonance imaging (MRI) of the brain revealing innumerable tiny foci of restricted diffusion, intracytoplasmic microvesicular fat on Sudan Red staining of bronchoalveolar lavage samples and evidence of a pulmonary shunt on echocardiogram bubble study. Red blood cell (RBC) exchange transfusion was initiated 3 days following initial presentation and no further exchange transfusions were needed on the basis of subsequent Hb S (HBB: c.20A>T) levels. The LOC gradually improved and the patient was extubated 12 days following presentation. Neurological improvement was slow, with mild cognitive impairment initially evident at 3 months and no cognitive or neurological deficits remaining within 6 months of admission. This case highlights the importance of understanding the pathophysiology and clinical presentation of FES, as early exchange transfusion may improve survival in patients with sickle cell disease and FES.
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Affiliation(s)
- Rochelle G Melvin
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Zachary Liederman
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Medical Oncology and Hematology, University Health Network, University of Toronto, Toronto General Hospital, Toronto, ON, Canada
| | - Sumedha Arya
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Lianne Rotin
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Christie M Lee
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Li Ka Shing Knowledge Institute, Toronto, ON, Canada
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17
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Ozdogu H, Boga C, Yeral M, Kozanoglu I, Gereklioglu C, Kocer NE. A Rare and Successfully Managed Complication of Stem Cell Transplantation in an Adult Patient With Sickle Cell Disease: Bone Marrow Necrosis. EXP CLIN TRANSPLANT 2021. [PMID: 34387156 DOI: 10.6002/ect.2021.0170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Sickle cell disease is the most common genetic disorder in the Eastern Mediterranean region where our transplant center is located. Today, adult patients with sickle cell disease can also be successfully treated with allogeneic hematopoietic stem cell transplantation. Bone marrow necrosis is a rare and serious clinical condition. Herein, we present this complication for the first time in the literature, which developed in the course of allogeneic hematopoietic stem cell transplantation and was successfully managed with additional bone marrow support. The recognition, prevention, and management of this rare and potentially fatal complication, bone marrow necrosis, are vitally important, especially in regions with high prevalence of sickle cell disease.
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Affiliation(s)
- Hakan Ozdogu
- From the Department of Hematology, Adana Adult Bone Marrow Transplantation Center, Baskent University, Ankara, Turkey
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18
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Tsitsikas DA, Mihalca D, Bello-Sanyaolu O, Amposah R, Olasoji S, Orebayo F, Tham L, Rowe S. Complete neurological recovery from fat embolism syndrome in sickle cell disease after sequential red cell exchange transfusion and therapeutic plasma exchange. Transfus Apher Sci 2021; 60:103226. [PMID: 34489185 DOI: 10.1016/j.transci.2021.103226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 07/27/2021] [Indexed: 11/29/2022]
Abstract
Fat embolism syndrome in sickle cell disease is associated with great mortality, while more than half of survivors suffer severe neurological sequelae. Release of fat droplets leads to obstruction of the microcirculation as well as generation of proinflammatory cytokines that can cause direct tissue injury. Red cell exchange transfusion can be life-saving but the addition of therapeutic plasma exchange may further improve outcomes by removing such inflammatory mediators. Here, we describe the case of a 27-year-old male patient with sickle cell anaemia presenting with typical features of fat embolism syndrome including neurological involvement with greatly reduced level of consciousness. MRI of his brain showed multiple widespread microhemorrhages giving the characteristic "star field" pattern but also a cytotoxic lesion of the corpus callosum, known to be the result of direct neurotoxicity by proinflammatory cytokines. The patient underwent emergency red cell exchange transfusion leading only to modest clinical improvement but fully regained consciousness after three cycles of therapeutic plasma exchange. This case highlights the deleterious effect of the hyperinflammatory state characteristic of many sickle cell complications and supports further exploring the potential benefit from plasma exchange as an adjunct to red cell exchange in order to remove proinflammatory cytokines during acute complications of sickle cell disease.
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Affiliation(s)
- Dimitris A Tsitsikas
- Haemoglobinopathy Service, Department of Haematology, Homerton University Hospital NHS Foundation Trust, London, UK.
| | - Diana Mihalca
- Haemoglobinopathy Service, Department of Haematology, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Oloruntoyin Bello-Sanyaolu
- Haemoglobinopathy Service, Department of Haematology, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Rhoda Amposah
- Haemoglobinopathy Service, Department of Haematology, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Susan Olasoji
- Haemoglobinopathy Service, Department of Haematology, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Funmilayo Orebayo
- Haemoglobinopathy Service, Department of Haematology, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Lawrence Tham
- Intensive Care Unit, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Susan Rowe
- Department of Radiology, Homerton University Hospital NHS Foundation Trust, London, UK
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19
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Lins CF, Salmon CEG, de Souza LA, Moraes RDS, Silva-Pinto AC, Matos MA, Nogueira-Barbosa MH. Qualitative and quantitative magnetic resonance imaging evaluation of bone tissue vaso-occlusive events in patients with sickle cell disease. Bone 2021; 148:115961. [PMID: 33866047 DOI: 10.1016/j.bone.2021.115961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/20/2021] [Accepted: 04/11/2021] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To evaluate the association between bone changes due to vaso-occlusive events in sickle cell disease (SCD) revealed by conventional MRI sequences and the fat fraction obtained using a 6-point DIXON technique (FFdix), in an attempt to use quantitative data as a biomarker for bone complications. METHODS Cross-sectional study, with 48 SCD patients, 26-homozygous (HbSS), and 22-compound heterozygous (HbSC). Forty-eight healthy individuals paired by age, weight, and sex with SCD patients. All participants underwent lumbar spine and pelvis MRI. Conventional sequences: bone complications related to vaso-occlusive events-femoral head avascular necrosis, bone infarctions, "H"-shaped vertebrae, bone marrow necrosis. Six-point DIXON technique: quantitative evaluation of the bone marrow at pre-established sites (lumbar vertebrae, sacrum, iliacs, femoral heads, greater femoral trochanters, femoral necks). Pearson's correlation, ROC curve, and binary logistic regression analysis were performed. RESULTS The most frequent findings in the SCD group included femoral head avascular necrosis (75%), bone infarctions (58.3%), "H"-shaped vertebrae (58.3%), and typical imaging findings of bone marrow necrosis (8.3%). Cortical bone thickness in the proximal femoral diaphysis in patients with SCD was moderately negatively correlated with FFdix in lumbar vertebrae, iliacs, femoral necks, and first sacral vertebrae. The ROC curves and odds ratios demonstrated excellent performance of FFdix in all the evaluated anatomical sites and identified patients having bone complications. CONCLUSIONS FFdix could serve as a potential biomarker in SCD because of its association with bone complications secondary to vaso-occlusive events in patients with SCD, especially in femoral heads, femoral necks, and iliacs.
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Affiliation(s)
- Carolina Freitas Lins
- Bahiana School of Medicine and Public Health (EBMSP), Av. Dom João VI, 275, Brotas, Salvador, Bahia, Brazil; Clínica Delfin Medicina Diagnóstica, Av. Antônio Carlos Magalhães, 442, Pituba, Salvador, Bahia, Brazil; Ribeirão Preto Medical School, USP Ribeirão Preto, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Campus Universitário s/n - Monte Alegre, Ribeirão Preto, SP, Brazil; Ribeirão Preto Medical School Musculoskeletal Imaging Research Laboratory, Brazil.
| | - Carlos Ernesto Garrido Salmon
- Faculdade de Filosofia, Ciências e Letras de Ribeirão Preto da Universidade de São Paulo (FFCLRP-USP), Av. Bandeirantes, 3900, Bairro Monte Alegre, Ribeirão Preto, São Paulo, Brazil
| | - Luana Amorim de Souza
- Bahiana School of Medicine and Public Health (EBMSP), Av. Dom João VI, 275, Brotas, Salvador, Bahia, Brazil
| | - Roberta de Souza Moraes
- Centro Universitário Maurício de Nassau (UNINASSAU), Rua dos Maçons, 364, Pituba, Salvador, Bahia, Brazil
| | - Ana Cristina Silva-Pinto
- Ribeirão Preto Medical School, USP Ribeirão Preto, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Campus Universitário s/n - Monte Alegre, Ribeirão Preto, SP, Brazil
| | - Marcos Almeida Matos
- Bahiana School of Medicine and Public Health (EBMSP), Av. Dom João VI, 275, Brotas, Salvador, Bahia, Brazil
| | - Marcello H Nogueira-Barbosa
- Ribeirão Preto Medical School, USP Ribeirão Preto, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Campus Universitário s/n - Monte Alegre, Ribeirão Preto, SP, Brazil; Ribeirão Preto Medical School Musculoskeletal Imaging Research Laboratory, Brazil; Department of Orthopedic Surgery, University of Missouri Health Care, Columbia, MO, United States
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20
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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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21
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Barouqa M, Szymanski J, Nelson R, Jofre S, Paroder M. Bone marrow necrosis and fat embolism syndrome in sickle cell disease: A rapidly deteriorating complication. Transfusion 2021; 61:1678-1679. [PMID: 33709429 DOI: 10.1111/trf.16367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/07/2021] [Indexed: 11/30/2022]
Affiliation(s)
| | - James Szymanski
- Pathology, Montefiore Medical Center, New York, New York, USA
| | - Randin Nelson
- Pathology, Montefiore Medical Center, New York, New York, USA
| | - Sebastian Jofre
- Montefiore Hospital and Medical Center, New York, New York, USA
| | - Monika Paroder
- Pathology, Montefiore Medical Center, New York, New York, USA
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22
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Timon C, Keady C, Murphy CG. Fat Embolism Syndrome - A Qualitative Review of its Incidence, Presentation, Pathogenesis and Management. Malays Orthop J 2021; 15:1-11. [PMID: 33880141 PMCID: PMC8043637 DOI: 10.5704/moj.2103.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Fat Embolism Syndrome (FES) is a poorly defined clinical phenomenon which has been attributed to fat emboli entering the circulation. It is common, and its clinical presentation may be either subtle or dramatic and life threatening. This is a review of the history, causes, pathophysiology, presentation, diagnosis and management of FES. FES mostly occurs secondary to orthopaedic trauma; it is less frequently associated with other traumatic and atraumatic conditions. There is no single test for diagnosing FES. Diagnosis of FES is often missed due to its subclinical presentation and/or confounding injuries in more severely injured patients. FES is most frequently diagnosed using the Gurd and Wilson criteria, like its rivals it is not clinically validated. Although FES is a multi-system condition, its effects in the lung, brain, cardiovascular system and skin cause most morbidity. FES is mostly a self-limiting condition and treatment is supportive in nature. Many treatments have been trialled, most notably corticosteroids and heparin, however no validated treatment has been established.
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Affiliation(s)
- C Timon
- Department of Trauma and Orthopaedics, Galway University Hospitals, Galway, Ireland
| | - C Keady
- Department of Trauma and Orthopaedics, Galway University Hospitals, Galway, Ireland
| | - C G Murphy
- Department of Trauma and Orthopaedics, Galway University Hospitals, Galway, Ireland
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23
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Elenga N, Bansie R. Fatal viral infections in hemoglobin sickle cell C patients. Pediatr Blood Cancer 2021; 68:e28668. [PMID: 32896961 DOI: 10.1002/pbc.28668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 08/07/2020] [Accepted: 08/09/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Narcisse Elenga
- Service de Médecine et Chirurgie Pédiatrique, Centre Hospitalier de Cayenne, Cayenne, Guiana.,Centre de référence de la drépanocytose aux Antilles-Guyane, Cedex, Cayenne, Guiana
| | - Rakesh Bansie
- Department of Immunology, Academic Hospital Paramaribo, Paramaribo, Suriname
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24
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Hashemzehi T, Bertok S, Figaszewska MJ, Batura D. Diverse manifestations of a sickle cell crisis. BMJ Case Rep 2021; 14:14/1/e236743. [PMID: 33509861 PMCID: PMC7845707 DOI: 10.1136/bcr-2020-236743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
We describe the case of a 21-year-old man with a background of sickle cell disease (SCD) who was on acute presentation in a sickle cell crisis required immediate intensive care admission with red blood cell exchange and ventilatory support. He had right frontal lobe infarcts and extensive bilateral deep white matter lesions most likely secondary to fat embolism. Inpatient investigations demonstrated a patent foramen ovale, explaining the route of spread of the fat embolus. He then had a transcatheter closure of the atrial defect. The patient needed prolonged inpatient rehabilitation. He was discharged from hospital in a wheelchair secondary to severe lower limb neurology and bilateral knee heterotopic ossification. He lives with the possibility of early onset dementia and cognitive decline, requiring constant care. The case highlights the multiple manifestations of SCD and their diverse and debilitating consequences.
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Affiliation(s)
- Tumaj Hashemzehi
- Medicine, London North West University Healthcare NHS Trust, Harrow, London, UK
| | - Szabolcs Bertok
- Department of Medicine for Older People and Neuro-Rehabilitation Medicine, London North West University Healthcare NHS Trust, Harrow, London, UK
| | | | - Deepak Batura
- Urology, London North West University Healthcare NHS Trust, Harrow, London, UK
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25
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Mallon D, Doig D, Dixon L, Gontsarova A, Jan W, Tona F. Neuroimaging in Sickle Cell Disease: A Review. J Neuroimaging 2021; 30:725-735. [PMID: 33463866 DOI: 10.1111/jon.12766] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 07/22/2020] [Indexed: 11/28/2022] Open
Abstract
Sickle cell disease is the most common hereditary hemoglobinopathy, which results in abnormally shaped and rigid red blood cells. These sickle-shaped red blood cells cause vaso-occlusion and ischemic phenomena that can affect any organ in the body. As a common cause of disability, the neurological manifestations of sickle cell disease are particularly important. Neuroimaging has a crucial role in the diagnosis, management, and prevention of the complications of sickle cell disease. These complications can affect the brain parenchyma, vasculature, and skull and can be ascribed directly or indirectly to a vasculopathy of small and large vessels. Vaso-occlusion can cause ischemic stroke. Ischemic damage in the absence of an acute neurological deficit, and therefore only apparent on neuroimaging, is termed silent cerebral ischemia. Weakening of the arterial walls can cause aneurysms. In its most severe form, a vasculopathy of the terminal internal carotid arteries can progress to moyamoya syndrome, characterized by steno-occlusive disease and the formation of friable collateral arteries. Rupture of aneurysms or friable collateral arteries is a potential cause of intracranial hemorrhage. The skull and vertebrae may be affected by extra-medullary hematopoiesis, due to severe anemia, or iron deposition, due to chronic red blood cell transfusion. Impaired blood supply to bone is associated with osteomyelitis and osteonecrosis. Fat embolization syndrome is a rare complication of osteonecrosis, which may cause devastating neurological impairment. Awareness and early recognition of the diverse manifestations of sickle cell disease on neuroimaging is crucial to ensure optimal treatment in a complex patient cohort.
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Affiliation(s)
- Dermot Mallon
- Imperial College NHS Healthcare Trust, Charing Cross Hospital, London, UK
| | - David Doig
- Imperial College NHS Healthcare Trust, Charing Cross Hospital, London, UK
| | - Luke Dixon
- Imperial College NHS Healthcare Trust, Charing Cross Hospital, London, UK
| | | | - Wajanat Jan
- Imperial College NHS Healthcare Trust, Charing Cross Hospital, London, UK
| | - Francesca Tona
- Imperial College NHS Healthcare Trust, Charing Cross Hospital, London, UK
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26
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Budhathoki N, Timilsina S, Ram B, Marks D. Bone marrow necrosis and fat embolism syndrome: a near fatal complication in previously undiagnosed sickle beta + thalassaemia. BMJ Case Rep 2021; 14:14/1/e238317. [PMID: 33408108 PMCID: PMC7789434 DOI: 10.1136/bcr-2020-238317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Prevalence of haemoglobin sickle-β+ thalassaemia (Hb S/β+thal) is variable with geography ranging from 0.2% to 10% among sickle cell patients. Clinical presentation of Hb S/β+thal patients depends on HbA level, with milder disease often going undiagnosed. However, rarely these patients can present with a fulminant vaso-occlusive crisis (VOC). Given VOC can present with non-specific symptoms, the diagnosis and treatment is often delayed. Here, we present a patient who initially developed altered mental status, pancytopenia and multiorgan failure due a critical VOC resulting in bone marrow necrosis and fat embolism. Subsequent workup confirmed that our patient had Sickle-β+ thalassaemia, which had gone undiagnosed, despite subclinical evidence of haemolysis on routine lab work for years. Following diagnosis and initiation of RBC exchange, he improved significantly and was discharged home. High index of suspicion and bone marrow biopsy is vital for early diagnosis and management of this rare condition.
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Affiliation(s)
- Nibash Budhathoki
- Hematology and Oncology, NYU Langone Hospital—Long Island, Mineola, New York, USA
| | - Sunita Timilsina
- Geriatrics, NYU Langone Hospital—Long Island, Mineola, New York, USA
| | - Bebu Ram
- Pathology, NYU Langone Hospital—Long Island, Mineola, New York, USA
| | - Douglas Marks
- Hematology and Oncology, NYU Langone Hospital—Long Island, Mineola, New York, USA
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27
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Madu AJ, Ugwu AO, Efobi C. Hyperhaemolytic Syndrome in Sickle Cell Disease: Clearing the Cobwebs. Med Princ Pract 2021; 30:236-243. [PMID: 33176303 PMCID: PMC8280419 DOI: 10.1159/000512945] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 11/10/2020] [Indexed: 12/23/2022] Open
Abstract
Sickle cell disease (SCD) presents with a dynamic background of haemolysis and deepening anaemia. This increases the demand for transfusion if any additional strain on haemopoiesis is encountered due to any other physiological or pathological causes. Patients with cerebrovascular accidents are placed on chronic blood transfusion; those with acute sequestration and acute chest syndrome are likewise managed with blood transfusion. These patients are prone to develop complications of blood transfusion including alloimmunization and hyperhaemolytic syndrome (HHS). This term is used to describe haemolysis of both transfused and "own" red cells occurring during or post-transfusion in sickle cell patients. Hyperhaemolysis results in worsening post-transfusion haemoglobin due attendant haemolysis of both transfused and autologous red cells. The mechanism underlying this rare and usually fatal complication of SCD has been thought to be secondary to changes in the red cell membrane with associated immunological reactions against exposed cell membrane phospholipids. The predisposition to HHS in sickle cell is also varied and the search for a prediction pattern or value has been evasive. This review discusses the pathogenesis, risk factors and treatment of HHS, elaborating on what is known of this rare condition.
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Affiliation(s)
- Anazoeze Jude Madu
- Department of Haematology and Immunology, University of Nigeria Ituku-Ozalla Campus, Ituku-Ozalla, Nigeria,
| | - Angela Ogechukwu Ugwu
- Department of Haematology and Immunology, University of Nigeria Ituku-Ozalla Campus, Ituku-Ozalla, Nigeria
| | - Chilota Efobi
- Department of Haematology, Nnamdi Azikiwe University, Nnewi, Nigeria
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Lampejo T. Parvovirus B19 infection as a potential trigger for fat embolism syndrome in patients with sickle cell disease. J Med Virol 2020; 93:3283-3284. [PMID: 33325058 DOI: 10.1002/jmv.26734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 12/07/2020] [Accepted: 12/12/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Temi Lampejo
- Department of Infection, Imperial College Healthcare NHS Trust, London, United Kingdom
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29
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Hequet O, Fort R, Driss F. Red blood cell exchange in an emergency in sickle cell disease. Transfus Apher Sci 2020; 59:102996. [PMID: 33189570 DOI: 10.1016/j.transci.2020.102996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Red blood cell exchange (RBCEx) has become a standard therapy to remove abnormal red blood cells (RBCs) in patients with sickle cell disease (SCD). In the last few decades, numerous RBCEx procedures have been performed chronically during regular programs, while numerous procedures have also been performed in an emergency for several indications, this therapeutic option being very efficient in vital and emergency situations. In both groups of indications, large amounts of sickle RBCs have to be removed, which requires great precision and the setting of specific hematological targets. The aim of this review is to discuss the aims, clinical and biological targets, and the requirements and precautions when performing RBCEx in an emergency. Moreover, we analyze how improvement of the techniques as well as the clinical and biological targets has led to optimization of the procedures in emergency settings. We also consider the outstanding issues that require additional investigation.
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Affiliation(s)
- O Hequet
- Apheresis Unit, Etablissement Français du Sang Auvergne Rhône-Alpes, Centre Hospitalier Lyon Sud, Pierre Bénite, France.
| | - R Fort
- Department of Internal Medicine, CHU Edouard Herriot, Lyon, France; Laboratoire LIBM EA7424, Equipe "Biologie Vasculaire et du Globule Rouge", Université Claude Bernard, Lyon, France; Laboratoire d'Excellence du Globule Rouge (LABEX GR-Ex), PRES Sorbonne, Paris, France
| | - F Driss
- Biological Hematological Unit, Centre Hospitalier universitaire Bicêtre, le Kremlin-Bicêtre, France
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30
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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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31
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Azul M, Shah S, Williams S, Vercellotti GM, Boucher AA. Evidence for complement-mediated bone marrow necrosis in a young adult with sickle cell disease. Blood Cells Mol Dis 2020; 86:102508. [PMID: 33096468 PMCID: PMC7546691 DOI: 10.1016/j.bcmd.2020.102508] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 09/25/2020] [Indexed: 01/08/2023]
Affiliation(s)
- Melissa Azul
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Mayo Clinic, Rochester, MN, USA
| | - Surbhi Shah
- Department of Medicine, Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Sarah Williams
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Gregory M Vercellotti
- Department of Medicine, Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Alexander A Boucher
- Department of Medicine, Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN, USA.
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32
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Ositelu A, Urrutia‐Argueta S, Kapoor R. Neurologic recovery in systemic nontraumatic fat embolism syndrome in an elderly patient with hemoglobin SC disease: A case report. Clin Case Rep 2020; 8:1816-1820. [PMID: 32983503 PMCID: PMC7495744 DOI: 10.1002/ccr3.3023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 04/14/2020] [Accepted: 05/15/2020] [Indexed: 11/09/2022] Open
Abstract
Cerebral fat embolism syndrome is an under-recognized yet well-known complication of bone marrow necrosis occurring in patients with sickle cell disease. We highlight a case manifested by multisystem organ failure in an elderly patient who attained neurologic recovery with prompt initiation of hematology consultation, RBC exchange, and supportive measures.
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Affiliation(s)
- Ayotunde Ositelu
- Department of Internal MedicineIndiana University School of MedicineIndianapolisINUSA
| | | | - Rajat Kapoor
- Division of Pulmonary and Critical Care MedicineDepartment of Internal MedicineIndiana University School of MedicineIndianapolisINUSA
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Gendreau S, Scholer M, Cecchini J, Habibi A, Razazi K, De Prost N, Carteaux G, Bartolucci P, Gendre T, Brugieres P, Hodel J, Mekontso Dessap A. Cerebral fat embolism in sickle cell disease. Am J Hematol 2020; 95:E41-E45. [PMID: 31736103 DOI: 10.1002/ajh.25686] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 11/09/2019] [Accepted: 11/13/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Segolene Gendreau
- Service de Réanimation Médicale, Hôpitaux Universitaires Henri Mondor—Albert Chenevier, DMU Médecine,Assistance Publique—Hôpitaux de Paris (AP‐HP) Créteil France
| | - Margaux Scholer
- Service de Radiologie, DMU FIXIT, Hôpitaux Universitaires Henri Mondor—Albert Chenevier, Assistance Publique—Hôpitaux de Paris (AP‐HP) Créteil France
| | - Jérôme Cecchini
- Service de Réanimation Médicale, Hôpitaux Universitaires Henri Mondor—Albert Chenevier, DMU Médecine,Assistance Publique—Hôpitaux de Paris (AP‐HP) Créteil France
- Service de Réanimation Adulte, Centre Hospitalier Intercommunal de Créteil Créteil France
| | - Anoosha Habibi
- Centre de référence des Maladies du Globule Rouge, DMU Médecine, Hôpitaux Universitaires Henri Mondor—Albert Chenevier, Assistance Publique—Hôpitaux de Paris (AP‐HP) Créteil France
- UPEC, Faculté de Médecine de Créteil, Institut Mondor de Recherche Biomédicale (IMRB), Institut National de la Santé et de le Recherche Médicale (INSERM) U955 DHU A‐TVB Créteil France
| | - Keyvan Razazi
- Service de Réanimation Médicale, Hôpitaux Universitaires Henri Mondor—Albert Chenevier, DMU Médecine,Assistance Publique—Hôpitaux de Paris (AP‐HP) Créteil France
| | - Nicolas De Prost
- Service de Réanimation Médicale, Hôpitaux Universitaires Henri Mondor—Albert Chenevier, DMU Médecine,Assistance Publique—Hôpitaux de Paris (AP‐HP) Créteil France
- Groupe de Recherche Clinique CARMASUniversité Paris Est‐Créteil Créteil France
| | - Guillaume Carteaux
- Service de Réanimation Médicale, Hôpitaux Universitaires Henri Mondor—Albert Chenevier, DMU Médecine,Assistance Publique—Hôpitaux de Paris (AP‐HP) Créteil France
- Groupe de Recherche Clinique CARMASUniversité Paris Est‐Créteil Créteil France
| | - Pablo Bartolucci
- Centre de référence des Maladies du Globule Rouge, DMU Médecine, Hôpitaux Universitaires Henri Mondor—Albert Chenevier, Assistance Publique—Hôpitaux de Paris (AP‐HP) Créteil France
- Service de Neurologie, DMU Médecine, Hôpitaux Universitaires Henri Mondor—Albert Chenevier, Assistance Publique—Hôpitaux de Paris (AP‐HP) Créteil France
| | - Thierry Gendre
- Service de Neurologie, DMU Médecine, Hôpitaux Universitaires Henri Mondor—Albert Chenevier, Assistance Publique—Hôpitaux de Paris (AP‐HP) Créteil France
| | - Pierre Brugieres
- Service de Radiologie, DMU FIXIT, Hôpitaux Universitaires Henri Mondor—Albert Chenevier, Assistance Publique—Hôpitaux de Paris (AP‐HP) Créteil France
| | - Jérôme Hodel
- Service de Radiologie, DMU FIXIT, Hôpitaux Universitaires Henri Mondor—Albert Chenevier, Assistance Publique—Hôpitaux de Paris (AP‐HP) Créteil France
| | - Armand Mekontso Dessap
- Service de Réanimation Médicale, Hôpitaux Universitaires Henri Mondor—Albert Chenevier, DMU Médecine,Assistance Publique—Hôpitaux de Paris (AP‐HP) Créteil France
- Groupe de Recherche Clinique CARMASUniversité Paris Est‐Créteil Créteil France
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34
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Lundeen KM, Bhoopal JR, Simegn MA, Leatherman JW. Acute Hypoxemia and Coma in a Patient With Hemoglobin SC Disease. Chest 2019; 155:e21-e23. [PMID: 30732697 DOI: 10.1016/j.chest.2018.10.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 07/18/2018] [Accepted: 10/12/2018] [Indexed: 10/27/2022] Open
Affiliation(s)
- Kayla M Lundeen
- Residency Program in Internal Medicine, Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Jaidev R Bhoopal
- Division of Pulmonary and Critical Care, Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Mengistu A Simegn
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - James W Leatherman
- Division of Pulmonary and Critical Care, Department of Medicine, Hennepin County Medical Center, Minneapolis, MN.
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35
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Maroni A, Dauger S, Chomton M. Fat Embolism Syndrome in a Child with Sickle Cell Disease. J Pediatr 2019; 214:236. [PMID: 31378517 DOI: 10.1016/j.jpeds.2019.06.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 06/05/2019] [Accepted: 06/07/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Arielle Maroni
- Pediatric Intensive Care Unit, Assistance Publique - Hôpitaux de Paris, Robert Debre University Hospital; Université de Paris, Paris, France
| | - Stéphane Dauger
- Pediatric Intensive Care Unit, Assistance Publique - Hôpitaux de Paris, Robert Debre University Hospital; Université de Paris; INSERM U1141, NEOPHEN Group, Robert Debre University Hospital, Paris, France
| | - Maryline Chomton
- Pediatric Intensive Care Unit, Assistance Publique - Hôpitaux de Paris, Robert Debre University Hospital, Paris, France
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36
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Elenga N, Celicourt D, Muanza B, Elana G, Hocquelet S, Tarer V, Maillard F, Sibille G, Divialle Doumdo L, Petras M, Tressières B, Etienne-Julan M. Dengue in hospitalized children with sickle cell disease: A retrospective cohort study in the French departments of America. J Infect Public Health 2019; 13:186-192. [PMID: 31548164 DOI: 10.1016/j.jiph.2019.07.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 01/18/2019] [Accepted: 07/22/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND To describe the characteristics of dengue in sickle cell children and try to identify risk factors of severity. METHODS In this retrospective study, we describe the evolution according to genotype (SS or SC and controls) and severity. RESULTS AND CONCLUSIONS From 2005 to 2013, 106 hospitalizations for dengue fever were recorded, 35 SS genotype, 35 SC and 36 without SCD or any other chronic disease. The clinical evolution was quite different. During hospitalization, SC patients were more likely to develop multiorgan failure (31.4% versus 25.7% for SS, and 0% for controls, p=0.001), or acute pulmonary complications than patients without SC sickle cell disease (14.3% versus 8.6% for SS, and 0% for controls, p=0.03). Level 3 analgesic treatment was more frequent in SC patients (22.9% versus 3% for SS, and 0% for controls, p<0.001). Patients with SC sickle cell disease had a higher proportion of severe forms of dengue (57.1% versus 37.1% for SS, and 0% for controls, p<0.001) than patients without SC sickle cell disease. Transfer in intensive care unit was required for most SC patients (22.9% versus 3% for SS, and 0% for controls, p=0.005).Fatal episodes were more frequent in SC patients than in patients without SC sickle cell disease (5 deaths versus 1 for SS and 0 for controls, p=0.02). Thirty-three patients (47.1%) were diagnosed as having severe dengue (13 SS and 20 SC). On univariate analysis, age >10 years, acute pulmonary complications, multiorgan failure, severe anemia requiring transfusion, use of antibiotic treatment, need for treatment with morphine, and longer hospital stay were statistically more frequent in severe dengue-associated cases. Multiple logistic regression analysis showed that HbSC genotype and acute pulmonary complications, were significantly associated with severe dengue. In the multivariate model, the area of the ROC curve was 0.831. Children with SC genotype, typically thought to have less severe disease, actually had a higher rate of severe dengue and death than those with SS genotype.
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Affiliation(s)
- Narcisse Elenga
- Service de Médecine et Chirurgie Pédiatrique, Centre Hospitalier de Cayenne, Centre de référence de la drépanocytose aux Antilles-Guyane, French Guiana; Centre de référence de la drépanocytose aux Antilles-Guyane, French Guiana.
| | - Donald Celicourt
- Service de Pédiatrie, Maison de la Mère et de l'Enfant, CHU de la Martinique, Centre de référence de la drépanocytose aux Antilles-Guyane, French Guiana; Centre de référence de la drépanocytose aux Antilles-Guyane, French Guiana
| | - Blandine Muanza
- Service de Pédiatrie, pôle Parents-Enfants, CHU de Pointe-à-Pitre/Abymes, Centre de référence de la drépanocytose aux Antilles-Guyane, French Guiana; Centre de référence de la drépanocytose aux Antilles-Guyane, French Guiana
| | - Gisèle Elana
- Service de Médecine et Chirurgie Pédiatrique, Centre Hospitalier de Cayenne, Centre de référence de la drépanocytose aux Antilles-Guyane, French Guiana; Service de Pédiatrie, pôle Parents-Enfants, CHU de Pointe-à-Pitre/Abymes, Centre de référence de la drépanocytose aux Antilles-Guyane, French Guiana
| | - Sévérine Hocquelet
- Service de Pédiatrie, pôle Parents-Enfants, CHU de Pointe-à-Pitre/Abymes, Centre de référence de la drépanocytose aux Antilles-Guyane, French Guiana
| | - Vanessa Tarer
- Centre de référence de la drépanocytose aux Antilles-Guyane, French Guiana
| | - Frédéric Maillard
- Service de Pédiatrie, pôle Parents-Enfants, CHU de Pointe-à-Pitre/Abymes, Centre de référence de la drépanocytose aux Antilles-Guyane, French Guiana; Centre de référence de la drépanocytose aux Antilles-Guyane, French Guiana
| | - Gérard Sibille
- Centre de référence de la drépanocytose aux Antilles-Guyane, French Guiana; Service de Pédiatrie, CH de la Basse-Terre, Centre de référence de la drépanocytose aux Antilles-Guyane, French Guiana
| | - Lydia Divialle Doumdo
- Centre de référence de la drépanocytose aux Antilles-Guyane, French Guiana; Unité Transversale de la Drépanocytose, pôle Parents-Enfants, CHU de Pointe-à-Pitre/Abymes, Centre de référence de la drépanocytose aux Antilles-Guyane, French Guiana
| | - Marie Petras
- Centre de référence de la drépanocytose aux Antilles-Guyane, French Guiana; Unité Transversale de la Drépanocytose, pôle Parents-Enfants, CHU de Pointe-à-Pitre/Abymes, Centre de référence de la drépanocytose aux Antilles-Guyane, French Guiana
| | - Benoit Tressières
- Centre d'Investigation Clinique Antilles-Guyane, Inserm CIC 1424, French Guiana
| | - Maryse Etienne-Julan
- Centre de référence de la drépanocytose aux Antilles-Guyane, French Guiana; Unité Transversale de la Drépanocytose, pôle Parents-Enfants, CHU de Pointe-à-Pitre/Abymes, Centre de référence de la drépanocytose aux Antilles-Guyane, French Guiana; UMR Inserm 1134/Université des Antilles-Guyane, French Guiana
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37
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Deucher A, Wool GD. How I investigate bone marrow necrosis. Int J Lab Hematol 2019; 41:585-592. [DOI: 10.1111/ijlh.13091] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 07/15/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Anne Deucher
- Department of Laboratory Medicine University of California San Francisco California
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38
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Stotesbury H, Kawadler JM, Hales PW, Saunders DE, Clark CA, Kirkham FJ. Vascular Instability and Neurological Morbidity in Sickle Cell Disease: An Integrative Framework. Front Neurol 2019; 10:871. [PMID: 31474929 PMCID: PMC6705232 DOI: 10.3389/fneur.2019.00871] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 07/26/2019] [Indexed: 12/20/2022] Open
Abstract
It is well-established that patients with sickle cell disease (SCD) are at substantial risk of neurological complications, including overt and silent stroke, microstructural injury, and cognitive difficulties. Yet the underlying mechanisms remain poorly understood, partly because findings have largely been considered in isolation. Here, we review mechanistic pathways for which there is accumulating evidence and propose an integrative systems-biology framework for understanding neurological risk. Drawing upon work from other vascular beds in SCD, as well as the wider stroke literature, we propose that macro-circulatory hyper-perfusion, regions of relative micro-circulatory hypo-perfusion, and an exhaustion of cerebral reserve mechanisms, together lead to a state of cerebral vascular instability. We suggest that in this state, tissue oxygen supply is fragile and easily perturbed by changes in clinical condition, with the potential for stroke and/or microstructural injury if metabolic demand exceeds tissue oxygenation. This framework brings together recent developments in the field, highlights outstanding questions, and offers a first step toward a linking pathophysiological explanation of neurological risk that may help inform future screening and treatment strategies.
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Affiliation(s)
- Hanne Stotesbury
- Developmental Neurosciences, UCL Great Ormond Institute of Child Health, London, United Kingdom
| | - Jamie M Kawadler
- Developmental Neurosciences, UCL Great Ormond Institute of Child Health, London, United Kingdom
| | - Patrick W Hales
- Developmental Neurosciences, UCL Great Ormond Institute of Child Health, London, United Kingdom
| | - Dawn E Saunders
- Developmental Neurosciences, UCL Great Ormond Institute of Child Health, London, United Kingdom.,Department of Radiology, Great Ormond Hospital, London, United Kingdom
| | - Christopher A Clark
- Developmental Neurosciences, UCL Great Ormond Institute of Child Health, London, United Kingdom
| | - Fenella J Kirkham
- Developmental Neurosciences, UCL Great Ormond Institute of Child Health, London, United Kingdom.,Clinical and Experimental Sciences, University of Southampton, Southampton, United Kingdom.,Department of Child Health, University Hospital Southampton, Southampton, United Kingdom.,Department of Paediatric Neurology, Kings College Hospital NHS Foundation Trust, London, United Kingdom
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39
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Manaresi E, Gallinella G. Advances in the Development of Antiviral Strategies against Parvovirus B19. Viruses 2019; 11:v11070659. [PMID: 31323869 PMCID: PMC6669595 DOI: 10.3390/v11070659] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 07/16/2019] [Accepted: 07/17/2019] [Indexed: 12/11/2022] Open
Abstract
Parvovirus B19 (B19V) is a human pathogenic virus, responsible for an ample range of clinical manifestations. Infections are usually mild, self-limiting, and controlled by the development of a specific immune response, but in many cases clinical situations can be more complex and require therapy. Presently available treatments are only supportive, symptomatic, or unspecific, such as administration of intravenous immunoglobulins, and often of limited efficacy. The development of antiviral strategies against B19V should be considered of highest relevance for increasing the available options for more specific and effective therapeutic treatments. This field of research has been explored in recent years, registering some achievements as well as interesting future perspectives. In addition to immunoglobulins, some compounds have been shown to possess inhibitory activity against B19V. Hydroxyurea is an antiproliferative drug used in the treatment of sickle-cell disease that also possesses inhibitory activity against B19V. The nucleotide analogues Cidofovir and its lipid conjugate Brincidofovir are broad-range antivirals mostly active against dsDNA viruses, which showed an antiviral activity also against B19V. Newly synthesized coumarin derivatives offer possibilities for the development of molecules with antiviral activity. Identification of some flavonoid molecules, with direct inhibitory activity against the viral non-structural (NS) protein, indicates a possible line of development for direct antiviral agents. Continuing research in the field, leading to better knowledge of the viral lifecycle and a precise understanding of virus–cell interactions, will offer novel opportunities for developing more efficient, targeted antiviral agents, which can be translated into available therapeutic options.
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Affiliation(s)
- Elisabetta Manaresi
- Department of Pharmacy and Biotechnology, University of Bologna, I-40138 Bologna, Italy
| | - Giorgio Gallinella
- Department of Pharmacy and Biotechnology, University of Bologna, I-40138 Bologna, Italy.
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40
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Lamotte G, Williams C. Mystery Case: A case of fulminant encephalopathy in a 69-year-old woman. Neurology 2019; 89:e109-e114. [PMID: 28847839 DOI: 10.1212/wnl.0000000000004288] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Guillaume Lamotte
- From the Department of Neurology (G.L.), Medstar Georgetown University Hospital; and Georgetown University School of Medicine (C.W.), Washington, DC.
| | - Cassie Williams
- From the Department of Neurology (G.L.), Medstar Georgetown University Hospital; and Georgetown University School of Medicine (C.W.), Washington, DC
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41
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Turkmen Samdanci E, Reha Celik M, Pehlivan S, Celbis O, Turkkan D, Ozdemir Kara D, Pamukcu E. Histopathological evaluation of autopsy cases with isolated pulmonary fat embolism (IPFE): is cardiopulmonary resuscitation a main cause of death in IPFE? Open Access Emerg Med 2019; 11:121-127. [PMID: 31239793 PMCID: PMC6559766 DOI: 10.2147/oaem.s194340] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 04/24/2019] [Indexed: 11/27/2022] Open
Abstract
Background: Fat embolism (FE) may develop following many traumatic and atraumatic clinical conditions; however, fewer data exist regarding the occurrence of isolated pulmonary FE (IPFE). Cardiopulmonary resuscitation (CPR) is an emergency procedure for maintaining blood circulation and oxygenation during cardiac arrest. In this study, we aimed to evaluate the association of CPR with IPFE in autopsy cases. Methods: A total 402 cases among 4,118 autopsies were diagnosed with IPFE, and the medical background of these cases was retrospectively evaluated. Diagnosis of FE and FE grading were performed with histopathological examinations of postmortem tissue samples, and injury-severity scores of traumatic cases were assessed. Data of traumatic and atraumatic cases were statistically compared. Results: Of the IPFE cases, 298 (741%) were male and 104 (25.9%) female, with overall mean age 53.7 (2–99) years. Causes of death of studied subjects were traumatic for 302 (75.1%) and atraumatic reasons for 100 (24.9%) cases. CPR was performed for 277 cases of which 177 (63.9%) were traumatic and 100 (36.1%) were non-traumatic. In comparison to traumatic cases, significantly higher CPR frequency was determined in atraumatic IPFE (P=0.001). High grade FE in the traumatic cases, and mild-moderate grade of FE in the nontraumatic cases were found statistically significant (P=0.001). Conclusion: This study indicates that CPR may be one of the leading factors in the development of IPFE in atraumatic conditions, and this procedure was related to mild–moderate IPFE manifestations. Regardless of whether conditions were traumatic or atraumatic, in patients who survive following CPR for manifest ventilation/perfusion problems, it should be remembered that IPFE may have developed due to CPR.
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Affiliation(s)
| | - Muhammet Reha Celik
- Department of Thoracic Surgery, School of Medicine, Inönü University, Malatya, Turkey
| | - Sultan Pehlivan
- Pathology Laboratory, Council of Forensic Medicine, Ankara Group Chairmanship, Ankara, Turkey
| | - Osman Celbis
- Department of Forensic Medicine, School of Medicine, Inönü University, Malatya, Turkey
| | - Dilhan Turkkan
- Pathology Laboratory, Council of Forensic Medicine, Ankara Group Chairmanship, Ankara, Turkey
| | - Dogus Ozdemir Kara
- Pathology Laboratory, Council of Forensic Medicine, Ankara Group Chairmanship, Ankara, Turkey
| | - Esra Pamukcu
- Department of Statistics, Faculty of Science, Fırat University, Elâziğ, Turkey
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Kishore J, Kishore D. Clinical impact & pathogenic mechanisms of human parvovirus B19: A multiorgan disease inflictor incognito. Indian J Med Res 2019; 148:373-384. [PMID: 30666000 PMCID: PMC6362725 DOI: 10.4103/ijmr.ijmr_533_18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Human parvovirus B19 (B19V) causes myriads of clinical diseases; however, owing to lack of awareness and undetermined clinical impact, it has failed to become a virus pathogen of global concern. Cryptically, B19V causes significant morbidity and mortality. Half of the world population and 60 per cent of Indians are known to be serologically naive and are at risk of acquiring B19V infections. Cumulatively, our data showed 21.3 per cent B19V-infected patients with juvenile chronic arthropathy, recurrent abortions, multi-transfused thalassaemia and leukaemia. In addition, B19V-infected cases that ended fatally included patients with pure red cell aplasia, fulminant hepatitis and haemophagocytic syndrome. Novel clinical associations of B19V observed were amegakaryocytic thrombocytopaenia, myositis and non-occlusive ischaemic gangrene of bowel. B19V possesses multiple receptors which are distributed widely in human tissues. Vascular endothelial cell infection by B19V causes endothelialitis and vasculitic injuries besides antibody-dependent enhancement which empowered B19V to cause multiorgan diseases. Owing to lack of suitable animal model for B19V, true causal role remains to be determined, but numerous reports on B19V infections substantiate a causal role in multiorgan diseases. Hence, B19V infections need to be recognized, investigated and treated besides making efforts on vaccine developments.
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Affiliation(s)
- Janak Kishore
- Division of Virology, Department of Microbiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Divya Kishore
- Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi, India
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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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Fort R. Recommendations for the use of red blood cell exchange in sickle cell disease. Transfus Apher Sci 2019; 58:128-131. [PMID: 30879904 DOI: 10.1016/j.transci.2019.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Sickle cell disease (SCD) is a genetic disorder characterised by a single mutation of the beta globin gene, causing the production of an abnormal haemoglobin called sickle haemoglobin (HbS). In its deoxygenated form, HbS polymerises, causing major rheological disorders, which presents clinically as periodic vaso-occlusive crises, chronic haemolysis and chronic vascular dysfunction. Patients often resort to a background treatment, and transfusion remains the cornerstone in the management of the disease, significantly reducing morbidity and mortality. The aim of red blood cell exchange (RBCX) is to improve tissue oxygenation by increasing haemoglobin levels while lowering HbS levels. RBCX can be performed by manual or automated exchange, and each technique has its own set of advantages and disadvantages. This article will outline the transfusion indications for the main complications of SCD, as well as the most appropriate strategy to use.
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Affiliation(s)
- Romain Fort
- Department of Internal Medicine, CHU Edouard Herriot, Lyon, France; Laboratoire LIBM EA7424, Equipe "Biologie Vasculaire et du Globule Rouge", Université Claude Bernard, Lyon, France; Laboratoire d'Excellence du Globule Rouge (LABEX GR-Ex), PRES Sorbonne, Paris, France.
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Abstract
Fat embolisms are fat globules that enter the circulatory system, typically through trauma, that may or may not lead to the development of fat embolism syndrome (FES), a rare and ill-defined diagnosis that can cause multiorgan failure and death. The exact mechanism of FES remains unknown, although several theories support the involvement of inflammatory response activation that contributes to characteristic clinical findings. There is no gold standard for diagnosis of FES, and treatment at this time remains primarily supportive. Early recognition of FES symptoms is the most beneficial nursing intervention for combating this serious disorder.
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Gangaraju R, May JE, Williams LA, Reddy VB, MacLennan P, Marques MB. Fat embolism syndrome due to bone marrow necrosis in patients with hemoglobinopathies: A life-threatening complication mimicking thrombotic thrombocytopenic purpura. Am J Hematol 2019; 94:E64-E66. [PMID: 30479040 DOI: 10.1002/ajh.25363] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 11/22/2018] [Indexed: 11/08/2022]
Affiliation(s)
- Radhika Gangaraju
- Division of Hematology‐Oncology, Department of MedicineUniversity of Alabama at Birmingham Birmingham Alabama
| | - Jori E. May
- Division of Hematology‐Oncology, Department of MedicineUniversity of Alabama at Birmingham Birmingham Alabama
| | - Lance A. Williams
- Division of Laboratory Medicine, Department of PathologyUniversity of Alabama at Birmingham Birmingham Alabama
| | - Vishnu B. Reddy
- Division of Laboratory Medicine, Department of PathologyUniversity of Alabama at Birmingham Birmingham Alabama
| | - Paul MacLennan
- Department of SurgeryUniversity of Alabama at Birmingham Birmingham Alabama
| | - Marisa B. Marques
- Division of Laboratory Medicine, Department of PathologyUniversity of Alabama at Birmingham Birmingham Alabama
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Duncan CN, Talano JAM, McArthur JA. Care of the Critically Ill Pediatric Sickle Cell Patient. CRITICAL CARE OF THE PEDIATRIC IMMUNOCOMPROMISED HEMATOLOGY/ONCOLOGY PATIENT 2019. [PMCID: PMC7122989 DOI: 10.1007/978-3-030-01322-6_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Sickle cell disease is the most common inherited disease in the United States. Through the effects of hemolysis and vaso-occlusion, it has the potential to incite critical illness involving multiple organ systems. Children with sickle cell disease are at risk of multiple types of shock resulting in a need for ICU care. Our youngest patients with sickle cell disease are at highest risk of infection due to lack of splenic function, and this can present with septic shock. Hypovolemic shock can occur secondary to severe acute anemia as seen with splenic sequestration or a delayed transfusion reaction. As one ages, the risk of cardiac dysfunction – diastolic and systolic dysfunction as well as pulmonary hypertension – can result in cardiogenic shock. In addition to shock, patients with sickle cell disease are at risk for respiratory failure from acute chest syndrome as well as acute neurologic deterioration from stroke. For these reasons, critical care physicians must be familiar with the unique management of sickle cell complications in order to provide the best possible care for this vulnerable population.
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Affiliation(s)
| | - Julie-An M. Talano
- Children’s Hospital of Wisconsin-Milwaukee, Medical College of Wisconsin, Milwaukee, WI USA
| | - Jennifer A. McArthur
- Department of Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN USA
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Cerebral fat embolism syndrome in sickle cell disease without evidence of shunt. eNeurologicalSci 2018; 14:19-20. [PMID: 30555946 PMCID: PMC6275165 DOI: 10.1016/j.ensci.2018.11.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 11/17/2018] [Indexed: 11/25/2022] Open
Abstract
Fat embolism syndrome (FES) is a known complication of sickle cell disease (SCD) that occurs secondary to vaso-occlusive crises, bone marrow infarction, and the subsequent release of fat globules into the venous circulation. Although neurologic involvement is common, the pathophysiology of cerebral fat emboli remains controversial. While fat microemboli can enter the arterial circulation through right-to-left shunts, the systemic release of free fatty acids may also cause indirect endothelial damage and disruption of the blood-brain-barrier. We present an unusual case of cerebral fat emboli in SCD that occurred in the absence of acute chest syndrome or right-to-left shunt, favoring a biochemical etiology. Treatment of FES includes supportive care and emergent red cell exchange transfusions. Cerebral fat embolism syndrome is a rare complication of sickle cell disease. Brain MRI shows multifocal punctate infarcts and hemorrhages in a “starfield” pattern. Fat microemboli can enter the brain through intrapulmonary or intracardiac shunts. In the absence of shunting, free fatty acids may cause indirect endothelial damage. Treatment involves supportive care and red cell exchange transfusions.
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Cho SM, Ling G, Rivera-Lara L. Cerebral microhemorrhages and cerebral fat embolism in hemoglobin S-C disease. Neurol Clin Pract 2018; 9:e13-e14. [PMID: 31041140 DOI: 10.1212/cpj.0000000000000559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 09/12/2018] [Indexed: 11/15/2022]
Affiliation(s)
- Sung-Min Cho
- Neurosciences Critical Care Division, Departments of Neurology, Anesthesiology, and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Geoffrey Ling
- Neurosciences Critical Care Division, Departments of Neurology, Anesthesiology, and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lucia Rivera-Lara
- Neurosciences Critical Care Division, Departments of Neurology, Anesthesiology, and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
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50
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Affiliation(s)
- Giorgio Gallinella
- Department of Pharmacy and Biotechnology, University of Bologna, Bologna, Italy
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