Acute Chest Syndrome: The Daily PANCE Blueprint
A 19-year-old man with known sickle cell disease presents with 1 day of fever, pleuritic chest pain, cough, and worsening shortness of breath. Temperature is 38.7°C (101.7°F), respiratory rate 28/min, and oxygen saturation 88% on room air. A chest radiograph shows a NEW infiltrate in the left lower lobe that was not present on a film last month. Which of the following is the most likely diagnosis?
A. Acute chest syndrome
B. Pulmonary embolism
C. Community-acquired pneumonia
D. Uncomplicated vaso-occlusive pain crisis
E. Splenic sequestration
Answer and topic summary
The answer is A. Acute chest syndrome.
In a patient with sickle cell disease, the combination of fever, respiratory symptoms (chest pain, cough, dyspnea), hypoxia, and a NEW pulmonary infiltrate on chest radiograph defines acute chest syndrome — a leading cause of death in sickle cell disease and a medical emergency. It is treated with oxygen, antibiotics, pain control, hydration, and transfusion (exchange transfusion for severe cases). Pneumonia and pulmonary embolism can mimic or trigger it, but the defining sickle-cell diagnosis with a new infiltrate is acute chest syndrome. A vaso-occlusive pain crisis lacks a new infiltrate/hypoxia, and splenic sequestration presents with a rapidly enlarging spleen and falling hemoglobin.
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