Thrombosis and gangrene in a patient with sickle cell disease and dactylitis

Determinants of severity in sickle cell disease

Sickle cell disease is a very variable condition, with outcomes ranging from death in childhood to living relatively symptom free into the 8^th decade. Much of this variability is unexplained. The co-inheritance of α thalassaemia and factors determining HbF levels significantly modify the phenotype, but few other significant genetic variants have been identified, despite extensive studies. Environmental factors are undoubtedly important, with socio-economics and access to basic medical care explaining the huge differences in outcomes between many low- and high-income countries. Exposure to cold and windy weather seems to precipitate acute complications in many people, although these effects are unpredictable and vary with geography. Many studies have tried to identify prognostic factors which can be used to predict outcomes, particularly when applied in infancy. Overall, low haemoglobin, low haemoglobin F percentage and high reticulocytes in childhood are associated with worse outcomes, although again these effects are fairly weak and inconsistent.

Ulcerative colitis in patients with sickle cell disease: a rare but important co-morbidity

COVID-19: Coronavirus disease 2019; HIC: high-income countries; IBD: inflammatory bowel disease; LMIC: low- and middle-income countries; PUCAL: paediatric ulcerative colitis activity index; SCD: sickle cell disease; UC: ulcerative colitis.

Amputations in Sickle Cell Disease: Case Series and Literature Review

In this study, we describe four new patients with sickle cell disease who had limb amputations. Two of the patients had sickle cell anemia [Hb S (HBB: c.20A > T) (β(S)/β(S))] with refractory leg ulcers that required amputations. The third patient had sickle cell trait with an extensive leg ulcer that was associated with epidermoid carcinoma. The fourth patient had amputations of both forearms and feet due to a misdiagnosis of dactylitis. Review of the literature showed that the indications for amputations in sickle cell disease included three distinct categories: mythical beliefs, therapeutic and malpractice. All therapeutic amputations were for severely painful, large, recalcitrant leg ulcers that failed non-interventional therapies. Amputation resulted in pain relief and better quality of life. Phantom neuropathic pain was not a major issue post-operatively. It was absent, transient or well controlled with antidepressants. Limb function was restored post-amputation with prosthetic artificial limbs, wheelchairs or crutches. Malpractice amputations were due to misdiagnosis or to cryotherapy by exposing the painful limb to ice water resulting in thrombosis, gangrene and amputation. We strongly suggest that leg amputations should be considered in the management of certain patients with severe extensive refractory leg ulcers, and topical cryotherapy should never be used to manage sickle cell pain.

Musculoskeletal Manifestations of Sickle Cell Disease: A Review

Sickle cell disease (SCD) is an inherited disorder of abnormal haemoglobin commonly encountered in the West African sub-region. It has varied osteoarticular and non-osseous complications that mimic some surgical conditions. The most common orthopaedic complications include avascular necrosis, osteomyelitis, septic arthritis, etc. A cautious and painstaking evaluation is required in handling these patients. Acute care and anaesthetic precautions are vital in ensuring an uneventful postoperative period.

Environmental determinants of severity in sickle cell disease

Sickle cell disease causes acute and chronic illness, and median life expectancy is reduced by at least 30 years in all countries, with greater reductions in low-income countries. There is a wide spectrum of severity, with some patients having no symptoms and others suffering frequent, life-changing complications. Much of this variability is unexplained, despite increasingly sophisticated genetic studies. Environmental factors, including climate, air quality, socio-economics, exercise and infection, are likely to be important, as demonstrated by the stark differences in outcomes between patients in Africa and USA/Europe. The effects of weather vary with geography, although most studies show that exposure to cold or wind increases hospital attendance with acute pain. Most of the different air pollutants are closely intercorrelated, and increasing overall levels seem to correlate with increased hospital attendance, although higher concentrations of atmospheric carbon monoxide may offer some benefit for patients with sickle cell disease. Exercise causes some adverse physiological changes, although this may be off-set by improvements in cardiovascular health. Most sickle cell disease patients live in low-income countries and socioeconomic factors are undoubtedly important, but little studied beyond documenting that sickle cell disease is associated with decreases in some measures of social status. Infections cause many of the differences in outcomes seen across the world, but again these effects are relatively poorly understood. All the above factors are likely to account for much of the pathology and variability of sickle cell disease, and large prospective studies are needed to understand these effects better.

Gangrene of the digits of the right lower limb in a patient with homozygous sickle cell disease and ulcerative colitis

Thrombosis may play an important role in the pathophysiology of certain complications of sickle cell disease (SCD). While the association between SCD and ulcerative colitis (UC) is still debatable, inflammatory bowel disease is known to be associated with an increased incidence of thromboembolic disease. We report a case of a 16-year old girl known to have homozygous SCD and also diagnosed with UC who presented with digital ischemia of her right lower limb. This led to gangrene and subsequent amputation of the first, second and third digits of that limb. This case highlights that patients with both UC and SCD may have an increased risk of thromboembolism and raises the question as to whether patients with UC and SCD should be screened for thrombophilia.

Limb amputation in hemoglobin SC disease after application of ice and elevation

A 31-year-old man with hemoglobin SC disease was admitted with acute chest syndrome, treated with antibiotics and ventilator support. His restrained right wrist and hand became swollen and cool, thought due to infiltration of an intravenous line. The hand was elevated, ice packs applied around the clock, and prophylactic low molecular weight heparin given. The arm quickly turned gangrenous. In spite of attempted thrombectomy and red blood cell exchange transfusion, amputation was required. Cold, elevation, and measures that reduce blood flow are known precipitators of sickling and crises. Vasoocclusion of the extremities to the point of gangrene is rarely reported in sickle cell disorders, and this case highlights the dangers of measures limiting blood flow in such patients.

Bone and joint disease in sickle cell disease

Bone and joint disorders are the most common cause of chronic pain in patients who have sickle cell disease. The femoral head is the most common area of bone destruction in sickle cell patients, although other disease-related problems include avascular necrosis of the humeral head, changes in the thoracic and lumbar spine, infection with encapsulated organisms (Salmonella and Staphylococcus aureus are the most common), bone marrow disturbances, and dental effects. Complications can occur at any location: epiphyseal, metaphyseal, or diaphyseal. The location and the extensiveness of the problems determine the pain and structural damage. The hip joint is particularly vulnerable in sickle cell disease. This article highlights aspects of sickle cell disease that affect healthy bone and joint function and discusses treatment options.