Orbital involvement in sickle cell disease: a report of five cases and review literature

Bone Turnover Markers Levels in a Cohort of Egyptian Children with Sickle Cell Disease

Bony complications are variable and common in sickle cell disease. Bone turnover markers are a reflection of bone new bone formation or degradation. The aim of this study is to assess the level of bone turnover markers in patients with sickle cell disease. This case-control study included 40 patients with sickle cell disease and 40 age and sex matched controls. Detection of serum calcium, phosphorus, alkaline phosphatase, serum creatinine levels were done. Assessment of Urinary deoxypyridinoline, Urinary N-terminal telopeptide of type I collagen, and serum osteocalcin were done. Serum osteocalcin was significantly lower, urinary deoxypyridinoline, Urinary N-terminal telopeptide of type I collagen were significantly higher among cases than the control group. Best cut off point for urinary deoxypyridinoline and urinary N-terminal telopeptide of type I collagen were 85.9ng/mg creatinine and 167.4 ng/mg creatinine respectively. Significant bone disease in patients with sickle cell anemia may be reflected by high levels of urinary Deoxypyridinoline and N-telopeptide of type I collagen at or above the cut off value.

An Atypical Case of Orbital Wall Infarction Secondary to Sickle Cell Disease in an Adult and Review of Literature

Sickle cell disease is known to cause painful vaso-occlusive crises in long bones with large marrows. Orbital infarction is a rare complication of sickle cell disease and usually presents in children and adolescents with acute onset periocular swelling mimicking orbital cellulitis. The authors describe an atypical case of a 38-year-old man with homozygous sickle cell disease who presented with isolated, complete ptosis of his OD with minimal swelling. He described brow aches on the same side, with no features of proptosis, ophthalmoplegia, or compressive optic neuropathy. Orbital imaging revealed infarction in the right frontal bone and orbital roof, with inflammatory soft tissue swelling. His condition resolved completely after 4 days with conservative medical therapy alone.

Painless recurrent orbital wall infarction secondary to sickle cell disease: A case report

Purpose

Describe the various presentations of the rare entity of orbital wall infarction secondary to sickle cell disease and highlight the importance of magnetic resonance imaging in differentiating the entity from other similar diagnoses.

Observation

A 4-year-old child presented to the hospital with bilateral recurrent painless orbital wall infarction secondary to sickle cell disease. Orbital wall infarctions have been described before in the literature; However, the painless and recurrent nature is intriguing.

Conclusion

Orbital wall infarctions secondary to sickle cell disease represent an unusual presentation of the disease and often pose a diagnostic dilemma. When considering differentiating orbital wall infarctions from other resembling entities, magnetic resonance imaging is considered superior to computed tomography due to its ability to delineate the ischemic changes in the bone marrow, which further aids in the diagnosis. In situations where the orbital wall infarction does not lead to orbital compression syndrome, a conservative approach should suffice.

Spontaneous Extradural Hematoma in a Sickle Cell Anemia Patient with Hyperinflammation and Thrombotic Microangiopathy Successfully Treated with Eculizumab: A Case Report and Review of the Literature

BACKGROUND

 The event of extradural hematoma in the absence of head trauma is a rare central nervous system complication of sickle cell disease. We report here a case of spontaneous extradural hematoma in a patient being treated for sickle cell vasoocclusive crisis complicated by hyperinflammation and thrombotic microangiopathy. The significance of inflammation as an integral component of the pathomechanism of vasoocclusive crisis in patients with sickle cell disease and the role of heme in activating the complement system's alternative pathway are highlighted in this case report.

CASE PRESENTATION

 A teenage patient with sickle cell disease developed a spontaneous right parietal extradural hematoma while receiving treatment for sickle cell vasoocclusive crisis. The concurrent events of hyperinflammation, disseminated intravascular coagulation, hyperhemolysis syndrome, thrombotic microangiopathy, and refractory postoperative bleeding complicated this patient's clinical course after surgical evacuation of extradural hematoma. This patient was subsequently treated with eculizumab and improved in the days following.

CONCLUSION

 Treatment with the anti-C5 monoclonal antibody eculizumab, which targets and inhibits terminal complement system activation, reversed the deleterious cascade of events in this patient with sickle cell disease.

Non-traumatic bilateral epidural hematoma in a child with sickle cell anemia: A case report and a review of the literature

OBJECTIVE

To report a rare case of spontaneous bilateral epidural hematoma (EDH) in a 10-year-old Nigerian child with sickle cell disease (SCD) and review the literature regarding this unusual complication.

METHODS

We present a case of a pediatric patient with SCD who developed a spontaneous bilateral EDH and discuss the potential underlying mechanisms, management approaches, and outcomes. We also conducted a literature review of existing cases of spontaneous EDH in patients with SCD.

RESULTS

Our patient initially presented with a subgaleal hematoma and underlying bilateral EDH, but she was sent home without any neurosurgical consultation. Two years later, she returned with altered consciousness and left-sided weakness, revealing an increased size of the EDH with a noticeable mass effect. She underwent a successful emergency bilateral craniotomy, with noticeable improvement in her level of consciousness and left-sided weakness post-operatively. In our literature review, we found 40 reported cases of spontaneous EDH in SCD patients, with a male predominance (82.5%). The average age of patients was 15.282 years. The most common hematoma location was bifrontal (20%) and the most reported symptom was headache (47.5%). Most patients (97.5%) were already known cases of SCD. Among those treated, 77.5% survived.

CONCLUSION

Spontaneous bilateral EDH in SCD patients is an uncommon complication, with a variety of proposed pathophysiological mechanisms. Prompt recognition and appropriate management, either conservative or surgical, are crucial to improve outcomes. Our case and literature review underscore the importance of considering spontaneous EDH in SCD patients presenting with neurological symptoms, even in the absence of trauma. Further research is needed to elucidate the precise etiology, identify risk factors, and optimize management approaches for this rare complication in SCD patients.

Massive spontaneous subdural hemorrhage mimicking dural venous thrombosis in a sickle cell adolescent, a rare case report

INTRODUCTION

Sickle cell disease is one of the most common hemoglobinopathies in Africa. Tanzania alone accounts for about 11,000 sickle cell births annually making it one of the most common disorders in eastern Africa. The affected individuals are prone to several complications since childhood as a result of the defective hemoglobin structure, these include neurological complications such as ischemic stroke due to hypercoagulability state caused by the disease. Spontaneous intracranial hemorrhage such as subdural hemorrhage in the absence of predisposing factors such as trauma, anticoagulant use, or recent blood transfusions is rare. As reported in the previous literature.

CASE PRESENTATION

We report a rare case of acute spontaneous subdural hemorrhage in an adolescent sickle cell patient of African descent.

DISCUSSION

Initial management including early referral and medical treatment is crucial for cases that are suspicious of intracranial hemorrhage. These cases are more common to be missed in resource-limited settings where there are a limited number of neurosurgery interventions.

CONCLUSION

Although few reported cases of spontaneous intracranial hemorrhage in sickle cell patients are reported, it is important to be vigilant as a clinician wherever a sickle cell patient presents with signs of increased intracranial pressure without a history of trauma such as in our patient and order an urgent brain imaging to rule out spontaneous hemorrhagic events which may lead to fatal consequences if missed out.

Extraocular Orbital and Peri-Orbital Masses

In this article, we will describe relevant anatomy and imaging findings of extraocular and orbital rim pathologic conditions. We will highlight important clinical and imaging pearls that help in differentiating these lesions from one another, and provide a few practical tips for challenging cases.

Skeletal manifestations of disease experience: Length of illness and porous cranial lesion formation in a contemporary juvenile mortality sample

OBJECTIVES

Porous lesions of the orbit (cribra orbitalia [CO]) and cranial vault (porotic hyperostosis [PH]) are used as skeletal indicators of childhood stress. Because they are understudied in contemporary populations, their relationship to disease experience is poorly understood. This paper examines the relationship between length of childhood illness and CO/PH formation in a clinically documented sample. "Turning points," which identify the window for lesion formation for CO/PH, are defined, implications for hidden heterogeneity in frailty are considered.

METHODS

Data are from 333 (199 males; 134 females) pediatric postmortem computed tomography scans. Individuals died in New Mexico (2011-2019) and are 0.5 to 15.99 years (mean = 7.1). Length of illness was estimated using information from autopsy and field reports. Logistic regression was used to estimate predicted probabilities, odds ratios, and the temporal window for lesion formation.

RESULTS

Illness, single bouts, or cumulative episodes lasting over 1 month is associated with higher odds of CO; individuals who were never sick have lower odds of having PH. This relationship was consistent for fatal and incidental illnesses that did not cause death. The developmental window for CO formation appears to close at 8 years.

CONCLUSIONS

Those ill for over 1 month are more likely to have CO/PH than those with acute illnesses. Some individuals lived sufficiently long to form CO/PH but died of illness. Others with lesions died of circumstances unrelated to disease. This indicates hidden variation in robusticity even among ill individuals with CO/PH, which is vital in interpreting lesion frequencies in the archeological record.

Orbital bone infarction masquerading as preseptal cellulitis in a child with sickle beta-thalassaemia

Although several ophthalmic manifestations of sickle cell disease (SCD) are common, orbital bone infarction is rare. Orbital bones have less bone marrow creating an unlikely place to develop infarction. However, having a patient with SCD presenting with periorbital swelling should warrant imaging to rule out bone infarction. We present a case of a child with sickle beta-thalassaemia who was misdiagnosed with preseptal cellulitis in the right eye. Later upon review of the subtle signs of bone infarction in imaging, she was discovered to have orbital bone infarction.

Subperiosteal Orbital Hematoma: A Rare Clinical Manifestation of Sickle Cell Disease - A Case Report

Sickle cell disease (SCD), an inherited vaso-occlusive disorder, results in recurrent painful episodes and a variety of serious systemic complications that can lead to severe disabilities and even death. Here, we report a case of a 19-year-old African American patient with homozygous sickle cell trait who presented with right upper lid edema and ptosis, 3 days after his admission to the hospital following a sickle cell crisis. Initially, mistaken as a superinfection in the context of his disease, a diagnosis of orbital abscess was made. Intravenous antibiotics and a proper treatment plan were set accordingly. Only after extensive clinical and radiological examinations, it turned out to be an acute subperiosteal orbital hematoma, a rare clinical manifestation of SCD. The aim of our case report was to highlight the difference in orbital presentation between osteomyelitis and subperiosteal hematoma, as well as spreading awareness among medical professionals and especially ophthalmologists for this rare presentation of orbital wall infarction, as the initial differential diagnosis of SCD patients with ocular involvement.

Management of Salter-Harris Type 1 Fracture Complicated with Osteomyelitis in a Sickle Cell Disease Patient: A Case Report and Review of Literature

Salter-Harris fractures may occur due to a single injury or repetitive stress fractures on the extremities. Type I to III fractures are managed medically, while types IV and V, which are rare, are treated surgically. In the pediatric population, Salter-Harris I fractures of the distal tibia are commonly seen, and management of such fractures are well established in the literature. Despite the availability of a wide range of treatment for such fractures, osteonecrosis or avascular necrosis of the proximal femur can subsequently develop. Avascular necrosis is cell death secondary to metabolic disturbances, trauma, adverse effects of certain medications, or sickle cell disease. Avascular necrosis commonly affects the talus, humerus, or tibia in addition to the femoral head. Radiographic images are essential for prompt diagnosis and to minimize negative health outcomes in these patients. However, Salter-Harris I fracture in sickle cell patients can be very challenging due to these patients' vulnerability to bone infections and sickle cell crisis. In this case report, our patient with a history of sickle cell disease and with a diagnosis of Salter-Harris I fracture was treated with surgical intervention as type V, which is discussed in this article, and responded well to treatment. Thus, this case suggests a new approach to managing Salter-Harris I fractures complicated with osteomyelitis in sickle cell patients.

Isolated Unilateral Orbital Compression Syndrome in A 19-Year-Old Male With Homozygous Sickle Cell Disease

This study aimed to report a rare case of a rapidly progressive isolated unilateral orbital compression syndrome in a male with homozygous sickle cell disease, who presented with proptosis and optic nerve dysfunction. He neither had long bone pain crisis nor fever at the time of presentation that was managed surgically to preserve vision. Rapidly progressive left orbital swelling is observed in a 19-year-old homozygous sickle cell disease patient associated with severe pain, headache, and impaired vision. Computed tomography of the orbit confirmed the presence of a unilateral large superior sub-periosteal cystic mass. Surgical exploration via anterior orbitotomy revealed a large sub-periosteal hematoma occupying the superior orbit which was evacuated. The patient completely recovered within 14 days post-surgery and regained his vision. Orbital involvement in sickle cell disease is rare, however, it can occur as a sequela of vaso-occlusive crisis and bone marrow infarctions leading to bleeding and sub-periosteal hematomas in the orbit. Prompt diagnosis and management of orbital compression syndrome are crucial to prevent permanent optic nerve damage. Hence, cautious evaluation and close monitoring are important, especially in cases where surgical evacuation is indicated for quick recovery and prevention of visual loss.

Orbital compression syndrome in a Ugandan child with sickle cell disease: A case report

Orbital compression syndrome is a rare acute complication of sickle cell disease that may impair vision. Assessment by a multidisciplinary team incorporates detailed history and physical examination, fundoscopy, and appropriate imaging to exclude infections or neoplasms. Supportive treatment is adequate unless there is evidence of life-threatening space-occupying lesion warranting surgery.

Mechanisms of Bone Impairment in Sickle Bone Disease

Sickle bone disease (SBD) is a chronic and invalidating complication of Sickle cell disease (SCD), a multisystem autosomal recessive genetic disorder affecting millions of people worldwide. Mechanisms involved in SBD are not completely known, especially in pediatric age. Among the hypothesized pathogenetic mechanisms underlying SBD are bone marrow compensatory hyperplasia and bone ischemic damage, both secondary to vaso-occlusive crisis (VOC), which leads to cell sickling, thus worsening local hypoxia with a negative impact on osteoblast recruitment. Furthermore, the hypoxia is a strong activator of erythropoietin, which in turn stimulates osteoclast precursors and induces bone loss. Hemolysis and iron overload due to a chronic transfusion regimen could also contribute to the onset of bone complications. Vitamin D deficiency, which is frequently seen in SCD subjects, may worsen SBD by increasing the resorptive state that is responsible for low bone mineral density, acute/chronic bone pain, and high fracture risk. An imbalance between osteoblasts and osteoclasts, with a relative decrease of osteoblast recruitment and activity, is a further possible mechanism responsible for the impairment of bone health in SCD. Moreover, delayed pubertal growth spurt and low peak bone mass may explain the high incidence of fracture in SCD adolescents. The aim of this review was to focus on the pathogenesis of SBD, updating the studies on biochemical, instrumental, and biological markers of bone metabolism. We also evaluated the growth development and endocrine complications in subjects affected with SCD.

Acute Soft Head Syndrome (Subgaleal Haematoma) with Periorbital Oedema as a Rare Presentation in Sickle Cell Disease

Background

Sickle cell disease is a genetic condition frequently found in Africa and the Arabian Peninsula. Uncommon complications include subgaleal haematoma (soft head syndrome) and periorbital oedema.

Case presentation

A 17-year-old male patient presented with body aches and progressive right parieto-temporal and frontal head swelling. Physical examination revealed puffiness of the right eye that progressed rapidly to reddish periorbital oedema sparing the extraocular muscle and pupil response to light. CT and MRI of the brain suggested multiple subgaleal haematomas (soft head syndrome) and right periorbital oedema.

Conclusion

Subgaleal haematoma (soft head syndrome) and periorbital oedema are uncommon complications of sickle cell disease. Management is conservative rather than surgical.

LEARNING POINTS

Subgaleal haematoma concurrently with periorbital oedema is a rare presentation of sickle cell disease.There are no guidelines on treatment, but the conditions in our patient resolved with conservative management.

Frontal Bone Infarctions Masquerading as Bilateral Orbital Cellulitis in a Patient with Sickle Cell Disease

Repeated vaso-occlusive crises (VOCs) are the hallmark of sickle cell disease (SCD). These repeated crises can lead to bone infarcts, necrosis, and, over time, degenerative changes in the bone marrow. Orbital complications in SCD patients are infrequent and usually present as orbital cellulitis. We report the appearance of orbital bone infarction intraoperatively in the case of an 18-year-old Saudi male patient who has been diagnosed with SCD and presented with severe headaches and generalized body aches. He was admitted with a case of SCD with acute VOC and started on the hospital sickle cell protocol. During the admission, the patient developed bilateral periorbital swelling and left inferior dystopia secondary to bilateral frontoparietal bone infarction, which was evident on the magnetic resonance imaging.

Spontaneous subgaleal hematoma in a patient with sickle cell disease: A case report and literature review

Sickle cell disease (SCD) is a common hemoglobin disorder with variable clinical manifestations. Spontaneous subgaleal hematoma is rare, with sporadic cases reported in patients with SCD. Most cases resolve with conservative measures. Skull bone infarction should be considered a possible cause of severe acute headache in patients with SCD.

Subperiosteal Hematoma of the Orbit: A Variety of Presentations

Subperiosteal hematoma of the orbit is an uncommon radiologic finding. Most typically, the hemorrhage is in the superior aspect of the orbit, however, location within the orbit may vary. Subperiosteal hematoma of the orbit may be associated with trauma. Nontraumatic etiology has also been well documented. We present a series of three cases, to illustrate typical and atypical radiologic findings of subperiosteal hematoma of the orbit, both traumatic and nontraumatic. Review of the pertinent radiologic literature and its relation to the cases presented here is also provided.

Spontaneous Epidural Hemorrhage in Sickle Cell Disease, Are They All the Same? A Case Report and Comprehensive Review of the Literature

Trauma to the skull causing injury to the middle meningeal artery, middle meningeal vein, or dural venous sinuses is responsible for most cases of epidural hemorrhage (EDH). Spontaneous EDH is a rare entity in clinical practice. Common causes include sinusitis, coagulation abnormalities, dural metastasis, and Langerhans cell histiocytosis. Isolated nontraumatic EDH is an exceedingly rare complication of sickle cell disease (SCD). We report a case of spontaneous EDH in a patient with SCD and review the world literature regarding this rare entity. A 20-year-old African American female with sickle cell disease presented with vaso-occlusive crisis. About 24 hours after hospital admission, the patient had sudden deterioration of her mental status. An emergent CT scan of the head revealed a large right-sided frontoparietal epidural hematoma with midline shift, subfalcine, and uncal herniation. The patient underwent emergent hematoma evacuation but died 24 hours after surgery.

Recurrent orbital bone sub-periosteal hematoma in sickle cell disease: a case study

BACKGROUND

Sickle cell disease is a common inherited hemoglobinopathy and is associated with high morbidity and mortality. Vaso-occlusive crises commonly occur in individuals with SCD that results in high morbidity due to end-organ ischemia and infarction. These include splenic infarction, pulmonary involvement, acute chest syndrome, and orbital compression syndrome. Ocular manifestations of SCD include anterior segment ischemia, secondary glaucoma, angoid streaks, retinopathy, and retinal artery occlusion. Commonly reported causes for the incidence of sickle cell disease are extreme temperatures, wind speed, and rainfall. This study has conducted an investigation of recurrent orbital bone sub-periosteal hematoma in a sickle cell patient that was exposed to high altitude areas.

CASE PRESENTATION

A 12-year-old boy with SCD developed a recurrent sudden periorbital pain and swelling during a visit to high altitude area. The family reported two similar attacks previously. The patient recovered completely with timely initiated conservative treatment. The case study is about homozygous SCD with previous history of similar attack of painful periorbital swelling that resolved after conservative management. This condition was associated with proptosis, diplopia, and restriction of eye movement. Magnetic resonance imaging of the orbits showed right orbital roof subperiosteal mass adjacent to the orbital wall, which was identified as a subperiosteal haematoma, inducing proptosis. The patient was discharged after 7 days with follow up.

CONCLUSIONS

Infarction of orbital bones during vaso-occlusive crises in SCD presented acutely with a rapidly progressive painful periorbital swelling. Hematomas frequently complicate the condition, along with the inflammatory swelling that may lead to the orbital compression syndrome. The condition is sight-threatening and necessitates prompt diagnosis along with appropriate management. This condition mandates prompt initiation of conservative treatment and close monitoring of the optic nerve functions to prevent permanent visual loss in young patients.

Iliopsoas hematoma in a patient with sickle cell disease

Although musculoskeletal pain in patients with sickle cell disease (SCD) is most frequently the result of vaso-occlusive episodes, clinicians often consider other etiologies including osteomyelitis, avascular necrosis, and trauma. In this study, we report the case of a young female with SCD with hip and back pain secondary to a nontraumatic iliopsoas periosteal hematoma with evidence of adjacent bone infarction. The pathophysiology, diagnostic considerations, and management of periosteal hematomas in SCD are reviewed. This case highlights the need for recognition of unusual causes of musculoskeletal pain in SCD.

Bilateral Subperiosteal Hematoma and Orbital Compression Syndrome in Sickle Cell Disease

A 14-year-old boy with sickle cell disease presented with preseptal cellulitis findings as proptosis, eyelid edema, and hyperemia. His best corrected visual acuity in the right eye was 20/20 and 16/20 in the left eye. He had limited ductions in vertical and lateral gazes in both eyes. Bilateral venous tortuosity was observed in posterior segment examination. Orbital bone infarction and subperiosteal hematoma were seen in magnetic resonance imaging. He was diagnosed as having orbital compression syndrome secondary to vaso-occlusive crisis of sickle cell disease and was treated with intravenous ampicilin-sulbactam and methylprednisolone.

Sickle cell disease and the eye

PURPOSE OF REVIEW

To review recent literature pertaining to sickle cell retinopathy (SCR) and, in particular, sickle cell maculopathy.

RECENT FINDINGS

Several recent studies suggest that macular perfusion abnormalities seen in patients with sickle cell disease of various genotypes may affect both the superficial and deep capillary plexi, with a predilection for the deep capillary plexus. Further, these changes may be associated with areas of macular thinning, as well as with peripheral retinal ischemia, even in individuals without visual symptoms, contrary to what has previously been described in both diabetic retinopathy and retinal vein occlusion. Several cases also suggest that paracentral acute middle maculopathy may be the pathophysiologic mechanism by which microvascular occlusion leads to macular thinning.

SUMMARY

Sickle cell disease can manifest in a number of ways within the orbit as well as intraocularly because of its nonspecific vasoocclusive episodes. However, SCR is the most common ophthalmic manifestation of this disease. Historically, SCR has been considered a peripheral retinopathy, but the development and use of spectral-domain optical coherence tomography and optical coherence tomography angiography suggest that significant macular vascular changes occur early in this disease, even in asymptomatic individuals.

Cranial epidural hematomas: A case series and literature review of this rare complication associated with sickle cell disease

BACKGROUND

Patients with sickle cell disease (SCD) may experience many complications of the central nervous system (CNS) including stroke, silent cerebral infarcts, and neuropsychological deficits. Cranial epidural hematoma is a rare but potentially serious complication.

PROCEDURE

Case series of cranial epidural hematomas in children with SCD from three different institutions is considered, along with a literature review of cranial epidural hematomas in this population.

RESULTS

Seven children with SCD with cranial epidural hematomas were identified from three different institutions. All patients were male and the age at presentation ranged from 10 to 18 years. Two patients presented with headache (28.6%), while the rest had no neurologic symptoms at presentation. Four patients required urgent neurosurgical intervention (57.1%) and one patient died (14.3%). A literature review identified 18 additional cases of cranial epidural hematomas in children with SCD. Of these, treatment ranged from supportive care to neurosurgical intervention. Twelve patients completely recovered (66.7%), one patient had long-term cognitive impairment (5.6%), and four patients died (22.2%). Combined with our data, cranial epidural hematomas have a mortality rate of 20.0%.

CONCLUSIONS

Although rare, cranial epidural hematoma can be fatal and should be considered in patients with acute neurological symptoms.

Neuroimaging of ocular involvement in patients with sickle cell disease and review of the literature

Endophthalmitis is a rare cause of ocular infection that can be associated with immunocompromising conditions and, more rarely, with sickle cell disease. In this case report and review of the literature, we present a case of a young male with sickle cell disease who presented with rapidly progressive ocular pain, edema, erythema, and decreased visual acuity. The key radiological findings to suggest endophthalmitis were demonstrated using computed tomography and magnetic resonance imaging.

Orbital Infarction due to Sickle Cell Disease without Orbital Pain

Sickle cell disease is a hemoglobinopathy that results in paroxysmal arteriolar occlusion and tissue infarction that can manifest in a plurality of tissues. Rarely, these infarcted crises manifest in the bony orbit. Orbital infarction usually presents with acute onset of periorbital tenderness, swelling, erythema, and pain. Soft tissue swelling can result in proptosis and attenuation of extraocular movements. Expedient diagnosis of sickle cell orbital infarction is crucial because this is a potentially sight-threatening entity. Diagnosis can be delayed since the presentation has physical and radiographic findings mimicking various infectious and traumatic processes. We describe a patient who presented with sickle cell orbital crisis without pain. This case highlights the importance of maintaining a high index of suspicion in patients with known sickle cell disease or of African descent born outside the United States in a region where screening for hemoglobinopathy is not routine, even when the presentation is not classic.

Neurologic and Head and Neck Manifestations of Sickle Cell Disease

Sickle cell disease is a common, inherited disordered characterized by chronic hemolytic anemia with repetitive episodes of vasoocclusion resulting from deformed red blood cells. This article reviews the most significant neurologic and head and neck manifestations of this disease.

A review of spontaneous intracranial extradural hematoma in sickle-cell disease

Sickle-cell disease is common among patients of Afro-Caribbean origin. Though it can precipitate neurological conditions, it only rarely causes neurosurgical problems, with very few reported cases. We describe the case of a 7-year-old girl with a background of sickle-cell disease (SCD) brought into an acute neurosurgical unit in extremis, signs of a raised ICP, and with no history of recent trauma. Following further investigations, an acute drop in the hemoglobin and hematocrit levels were noted, with the cause of her presentation being attributed to a sickling crisis causing skull convexity infarction and resulting in spontaneous bilateral extradural hematomas requiring emergency evacuation. We review the current literature and propose the pathophysiological mechanism behind this phenomenon.

Sterile subperiosteal fluid collections accompanying orbital wall infarction in sickle-cell disease

Infarction of the orbital wall is an uncommon manifestation of sickle cell disease (SCD) that may mimic an infectious process. We report a patient with two separate orbital infarctions with different presenting symptoms involving different bones. Radiologic-guided sampling of a periosteal fluid collection in the first episode showed likely sterile inflammatory exudates. This case highlights the range of findings in orbital wall infarction in SCD as well as helpful clinical and imaging entities that may differentiate infarction from infection, allowing early diagnosis and appropriate management.

Orbital compression syndrome complicated by epidural hematoma and wide cephalohematoma in a patient with sickle cell disease

Orbital wall infarctions resulting in orbital and epidural hematomas are rare manifestations of sickle cell disease (SCD). We report orbital compression syndrome associated with an epidural hematoma and wide cephalohematoma in a 15-year-old boy with SCD. An infarcted orbital bone was observed on magnetic resonance imaging and three-phase bone scintigraphy with Technetium-99m methylene diphosphonate. The patient recovered completely without surgical intervention at the end of the fourth week. Prompt diagnosis and proper management are critical for complete recovery.

Non-traumatic spontaneous acute epidural hematoma in a patient with sickle cell disease

A 19-year-old female with sickle cell anemia (SCD) was referred to our hospital after two days of hospitalization at another hospital for a headache crisis. This headache crisis was due to a raised intracranial pressure; these symptoms were noted and included in her comprehensive list of symptoms. There was an acute drop in the hemoglobin and hematocrit levels. The cranial CT scan demonstrated a left fronto-parietal acute epidural hematoma (AEH) and a calvarial bone expansion, which was suggestive of medullary hematopoiesis. The patient underwent emergent craniotomy and evacuation of the hematoma. There were no abnormal findings intra-operatively apart from the AEH, except skull thickening and active petechial bleeding from the dural arteries. Repeated CT scan showed a complete evacuation of the hematoma. The possible underlying pathophysiological mechanisms were discussed. In addition to the factors mentioned in the relevant literature, any active petechial bleeding from the dural arteries on the separated surface of the dura from the skull could have contributed to the expanding of the AEH in our patient. Neurosurgeons and other health care providers should be aware of spontaneous AEH in patients with SCD.

Nontraumatic orbital hemorrhage

Nontraumatic orbital hemorrhage (NTOH) is uncommon. I summarize the published reports of NTOH and offer a classification based on anatomic and etiologic factors. Anatomic patterns of NTOH include diffuse intraorbital hemorrhage, "encysted" hemorrhage (hematic cyst), subperiosteal hemorrhage, hemorrhage in relation to extraocular muscles, and hemorrhage in relation to orbital floor implants. Etiologic factors include vascular malformations and lesions, increased venous pressure, bleeding disorders, infection and inflammation, and neoplastic and nonneoplastic orbital lesions. The majority of NTOH patients can be managed conservatively, but some will have visual compromise and may require operative intervention. Some will suffer permanent visual loss, but a large majority have a good visual outcome.

Bilateral orbital infarction and retinal detachment in a previously undiagnosed sickle cell hemoglobinopathy African child

Bone infarction involving the orbit in sickle cell disease is not common. Bilateral orbital infarction in a previously undiagnosed sickle cell hemoglobinopathy has not been previously reported. In this report, we present a case of an 11-year-old previously undiagnosed sickle cell disease Nigerian girl with severe acute bilateral orbital infarction and retinal detachment to highlight that hemoglobinopathy induced orbital infarction should be considered in African children with acute onset proptosis with or without previous history of sickle cell hemoglobinopathy.

Acute soft head syndrome in children with sickle cell anaemia in lagos, Nigeria

Acute soft head syndrome is rare complications seen in children with sickle cell anaemia. A case report of a child with sickle cell anaemia who developed acute soft head syndrome. A 12-year old known sickle cell anaemia patient presented with acute, rapidly progressive skull pain and swelling, manifestations indicative of the rare complication of SCD which is called acute soft head syndrome. Conservative treatment with intravenous fluids and analgesics and empirical use of broad-spectrum antibiotics resulted in recovery. Acute soft head syndrome is a rare complication in children with sickle cell anaemia probably related to skull infarction. It further draws attention to the importance of acute soft head syndrome as a differential to be considered for pains in the head and skull swellings in children with sickle cell anaemia.

Beyond the definitions of the phenotypic complications of sickle cell disease: an update on management

The sickle hemoglobin is an abnormal hemoglobin due to point mutation (GAG → GTG) in exon 1 of the β globin gene resulting in the substitution of glutamic acid by valine at position 6 of the β globin polypeptide chain. Although the molecular lesion is a single-point mutation, the sickle gene is pleiotropic in nature causing multiple phenotypic expressions that constitute the various complications of sickle cell disease in general and sickle cell anemia in particular. The disease itself is chronic in nature but many of its complications are acute such as the recurrent acute painful crises (its hallmark), acute chest syndrome, and priapism. These complications vary considerably among patients, in the same patient with time, among countries and with age and sex. To date, there is no well-established consensus among providers on the management of the complications of sickle cell disease due in part to lack of evidence and in part to differences in the experience of providers. It is the aim of this paper to review available current approaches to manage the major complications of sickle cell disease. We hope that this will establish another preliminary forum among providers that may eventually lead the way to better outcomes.

[Orbital bone infarction in a child with homozygous sickle cell disease]

Vaso-occlusive crises are the most common complication of sickle cell disease. Orbital bone infarction is an unusual manifestation of sickling disorders. It is suspected in patients with acute painful periorbital swelling. Orbital compression syndrome with possible optic nerve injury is a rare but serious complication; therefore, this diagnosis should be considered. Orbital infarction can be difficult to distinguish from osteomyelitis or skin infections. Imaging can be helpful in differentiating infection from infarction. We report a case of orbital bone infarction in a 14-year-old boy with sickle cell disease. Under medical treatment, the clinical course resolved with no sequelae.

Orbital infarction in sickle cell disease

PURPOSE

To determine the role of hematological and genetic factors in the development of orbital infarction in sickle cell disease.

DESIGN

Retrospective, noncomparative case series.

METHODS

Fourteen sickle cell disease patients were diagnosed with orbital infarction during a vaso-occlusive crisis. Clinical and radiological findings were reviewed retrospectively. Sickle cell disease patients without orbital infarction were recruited as controls after matching for disease severity. Sickle haplotypes were determined for all patients. Differences between groups were evaluated statistically.

RESULTS

Patients with orbital infarction in sickle cell disease presented with acute periorbital pain and swelling with or without proptosis, ophthalmoplegia, and visual impairment during a vaso-occlusive crisis. Radiological findings included orbital soft tissue swelling (100%), hematoma (orbital, 36%; intracranial, 21%), and abnormal bone marrow intensities. Severity of orbital involvement was unrelated to that of the systemic disease (Pearson correlation coefficient, -0.1567). Affected patients predominantly had the Benin haplotype (P < .00782).

CONCLUSIONS

Orbital infarction is a potential threat to vision in sickle cell disease patients. Magnetic resonance imaging is more specific than computed tomography or nuclear scintigraphy in the evaluation of orbital changes. The degree of severity of the orbital manifestations appears unrelated to the severity of sickle cell disease. Patients with the Benin haplotype are more likely to develop orbital infarction during vaso-occlusive crises.

Orbital compression syndrome in sickle cell disease

PURPOSE

To present 3 cases of orbital compression syndrome caused by infarction of the greater wing of the sphenoid in patients with sickle cell disease.

METHODS

Case report and review of the literature.

RESULTS

Three patients with sickle cell disease (2 males aged 22 and 16 years, and a 10-year-old girl) who presented with proptosis, limited ocular motility, and chemosis were found to have an infarction of the marrow space of the greater wing of the sphenoid that produced an orbital subperiosteal hemorrhage and exudate demonstrated on MRI. Two patients suffered compressive optic neuropathy; both patients recovered normal optic nerve function. Orbital edema resolved within 48 hours of receiving 1 g methylprednosolone daily. The third patient had normal optic nerve function and his orbital edema improved with methylprednisolone 250 mg/day and intravenous Kefzol over 3 days. In the literature, there are 27 similar cases; 5 were treated surgically and the remainder were managed medically.

CONCLUSIONS

Patients with sickle cell disease are at risk for orbital compression syndrome secondary to orbital bone infarction, in the setting of vaso-occlusive crises. This diagnosis should be considered when a patient with sickle cell disease presents with headache, proptosis, decreased motility, and/or optic nerve compromise.

Fever and Periorbital Edema: A Review

Fever and periorbital swelling are the manifestation of a broad array of diseases. Among them are emergency situations, which need prompt physician input. Swiftly formulating a differential diagnosis approach is crucial. Diseases causing fever and periorbital edema are either local or systemic. Nevertheless, their impact can be systemic if they evade diagnosis. Infectious diseases and non-infectious diseases (inflammatory and allergic diseases, autoimmune diseases, neoplastic diseases, and trauma) can all lead to fever and periorbital edema. A meticulous history and physical examination in association with targeted tests against the presented spectrum of diseases (specific serological tests, radiological tests, cultures taken from the surface of the periorbital area and other relevant areas, and skin biopsy for histological and microbiological examination) will clarify the diagnosis.