Which Febrile Children With Sickle Cell Disease Need a Chest X‐Ray?

Abstract

Objective Controversy exists regarding which febrile children with sickle cell disease (SCD) should receive a chest x‐ray (CXR). Our goal is to provide data informing the decision of which febrile children with SCD presenting to the emergency department (ED) require a CXR to evaluate for acute chest syndrome (ACS). Methods Retrospective chart review of children ages 3 months to 21 years with SCD presenting to the ED at one of two academic children's hospitals with fever ≥38.5°C between January 1, 2010, and December 31, 2012. Demographic characteristics, respiratory symptoms, and laboratory results were abstracted. The primary outcome was the presence of ACS. Binary recursive partitioning was performed to determine predictive factors for a diagnosis of ACS. Results A total of 185 (10%) of 1,837 febrile ED visits met ACS criteria. The current National Heart, Lung, and Blood Institute (NHLBI) consensus criteria for obtaining a CXR (shortness of breath, tachypnea, cough, or rales) identified 158 (85%) of ACS cases, while avoiding 825 CXRs. Obtaining a CXR in children with NHLBI criteria or chest pain and in children without those symptoms but with a white blood cell (WBC) count ≥18.75 × 109/L or a history of ACS identified 181 (98%), while avoiding 430 CXRs. Conclusion Children with SCD presenting to the ED with fever and shortness of breath, tachypnea, cough, rales, or chest pain should receive a CXR due to high ACS rates. A higher WBC count or history of ACS in a child without one of those symptoms may suggest the need for a CXR. Prospective validation of these criteria is needed.

What is the role of chest X‐ray imaging in the acute management of children with sickle cell disease?

“…When applying the tool to this cohort, the total number of CXRs performed would have been reduced by 63% ( n = 576), although this would be at the expense of missing 22 clinically significant CXRs (8·5%). This fits in with findings by Eisenbrown et al ., 27 who found that 98% of ACS cases could be identified when obtaining a CXR in children with NHLBI criteria, chest pain, ACS history or those with a WCC 18·75. The tool we propose has the potential to identify not only ACS but other clinically significant CXR findings, and to importantly reduce unnecessary CXRs.…”

Risk-Score Based Strategy to Minimize Antibiotic Exposure in Children With Sickle Cell Disease and Fever

“…Several studies had previously reported different predictors of bacteremia and other severe infections in patients with SCD, including elevated CRP, procalcitonin, WBC and neutrophils, toxic appearance, vomiting and long-term CVC 2,4,8,9 . IL-6 has also been recently described by our group as a marker of CSBI in these patients 6 .Other studies had also reported hipoxemia and elevated WBC or neutrophils as predictors of pneumonia or ACS 3,10 .…”

The prevalence of abnormal leukocyte count, and its predisposing factors, in patients with sickle cell disease in Saudi Arabia

“…This finding is consistent with several studies. 24 , 25 Eisenbrown et al 25 reported that a higher WBC level in SCD patients with a cough should prompt a chest X-ray.…”