DIAGNOSTIC EVALUATION FOR INFECTIOUS ETIOLOGY OF SICKLE-CELL PAIN CRISIS

Occult infections during sickle cell pain crisis can be associated wit h significant morbidity. It has been suggested that empiric workup for pneumonia and urinary tract infection (UTI) is required. A study was undertaken to determine whether clinical criteria can be used to exclu de such infections as precipitants of pain crisis in adults. This retr ospective, observational clinical study was conducted in an inner-city teaching hospital emergency department (ED) with 95,000 visits/year. Patients 18 years of age or older presenting to the ED with sickle cel l pain crisis who had not used antipyretics within 6 hours before pres entation were eligible. Ninety-four Visits were evaluated. During init ial evaluation the treating physician completed a questionnaire addres sing systemic, pulmonary, and urinary tract signs and symptoms. Temper ature and physical examination were recorded on an ED memo. Treatment modalities were at the discretion of the treating physician. All patie nts had a complete blood count, reticulocyte count, urinalysis, and ch est radiograph. if the urinalysis was positive (>2 white blood cells) or the patient had clinical evidence of a UTI, a urine culture was obt ained. UTI was confirmed through a urine culture with >100,000 colony- forming units/mL. Chest X-rays were reviewed by a staff radiologist. D efinitive diagnosis of pneumonia was made by the presence of an infilt rate and a positive clinical response to antibiotic therapy. Thirty ei ght patients totalling 94 visits to the ED were studied during an 18-m onth period. Six diagnoses of pneumonia and 3 diagnoses of UTI were ma de. All six patients with pneumonia had at least 4 of the signs and sy mptoms including fever, chills, cough, shortness of breath, sputum pro duction, chest pain, hemoptysis, abnormal pulmonary examination, and t emperature of >37.8 degrees C. Of the three patients with UTI, two had signs and symptoms inconsistent with UTI (asymptomatic bacteriuria). In patients with sickle cell pain crisis, medical history and physical examination can be useful to predict the absence of pneumonia, but ma y not be as beneficial in predicting the absence of UTI. These results suggest that empiric chest x-ray may be unnecessary to exclude pneumo nia; however, routine urinalysis may be indicated. Because of the low Incidence of these infections, larger studies are required to confirm these findings. Copyright a 1997 by W.B. Saunders Company.