Sudden Death During Prolonged Religious Fasting

Abstract

Sickle cell trait (SCT) is estimated to occur in 6% to 10% of Africans, and the United Kingdom (UK) prevalence rate has been estimated at 3.2%. Although sudden death in sickle cell disease is well known, its occurrence in SCT is rare and requires extremes of physiological stress. We present a case of a 29-year-old black woman who died suddenly during a period of religious fasting. Her medical history was unremarkable, and there was no family history of sickle cell disease. At postmortem, she was found to be dehydrated, and macroscopically, the main abnormal findings were congested lungs and a small spleen. Histological examination revealed extensive vascular congestion with red blood cell sickling in both lungs, the liver, and the spleen. Electrophoresis on a postmortem blood sample confirmed the clinical suspicion that the patient was a carrier of SCT. The case highlights a novel scenario of SCT associated sudden death. We discuss the potential pathophysiological mechanisms that may have led to the patient's demise. We also remind pathologists to consider this diagnosis as potentially contributing to the cause of death in apparently fit young people of ethnic origin during episodes of physiological stress.

Intraday Blood Rheological Changes Induced by Ramadan Fasting in Sickle Cell Trait Carriers

“…One report suggested that SCT could be a contributing factor in sudden death occurring during religious fasting (Biedrzycki & Sheaff 2010). Several epidemiological studies and case reports emphasized the possible role of SCT in idiopathic exercise sudden death (Anzalone et al, 2010;Ferster & Eichner, 2012;Harmon et al, 2012;Harris et al, 2012;Hedreville et al, 2009;Kark et al, 1987;Kerle & Nishimura, 1996;Pretzlaff, 2002).…”

“…Some recent studies demonstrated that dehydration may cause large hemorheological alterations in SCT carriers (Diaw et al, 2012;Tripette et al, 2010). Indeed, one could hypothesize that impaired blood rheology caused by dehydration during fasting could have been involved in the fatal event described by Biedrzycki and Sheaff (2010). Although several works have focused on the hemorheological changes caused by exercise in SCT carriers (Connes, 2010;Connes et al, 2008aConnes et al, , 2008bTripette et al, 2007Tripette et al, , 2013, no study focused on the hemorheological modifications caused by fasting Ramadan in nonexercising SCT carriers, as well as in the general population.…”

“…Altered hemorheological parameters, including elevated blood viscosity, are thought to play a significant role in the occurrence of such complications (Connes, 2010;Tripette et al, 2007). Recently, Biedrzycki & Sheaff (2010) reported the case of a 29-yr-old black woman carrying SCT who died after 20 d of prolonged religious fasting. The authors suggested that SCT could have been a precipitating factor in the occurrence of this fatal event.…”