Pam Leece, Student #4346746
RADIOLOGY CASE REPORT
Patient ID: OH#_____34285916____
Date of Study: ____April 7, 2008____
Patient Name: __Melissa Uzamukunda_ Type of Study: ___Chest – PA and lateral _
1. Clinical Indication: ___ a 20 year old African woman with sickle cell disease presents
to the emergency department with back pain __
2. Picture:
Pam Leece, Student #4346746
2. Describe the radiological findings:
There is evidence of fibrosis and decreased volume in the right upper lobe
(present on previous studies). The upper thoracic spine shows mild scoliosis convex left.
There are several thoracic vertebral bodies that appear to have biconcave deformities.
There is no evidence of pleural effusion, pulmonary edema, consolidation, or
cardiomegally.
Pam Leece, Student #4346746
3. Provide possible diagnosis(es):
We know that this patient has sickle cell disease and there are findings on chest
radiography that are consistent with chronic changes seen in sickle cell disease. Chronic
changes among patients with sickle cell disease include lung fibrosis as a sequela of
microvascular occlusion and infarct, as well as skeletal abnormalities, such as rib
infarction, extramedullary hematopoesis, and vertebrae deformities (Leon and Stark,
1998). Cardiomegally may be present due to hyperkinetic circulation and renal
insufficiency (Leon and Stark, 1998).
Pleural effusions, pulmonary consolidation, and pulmonary edema may be present
due to more acute processes such as pneumonia or acute chest syndrome (Leon and Stark,
1998). Acute chest syndrome is described as a new focus of opacity in the lung, along
with symptoms such as fever, leukocytosis, hypoxia and chest pain (Madani et al 2007).
The radiographs for this patient specifically demonstrate lung fibrosis and
vertebral body deformity. Deformities in vertebral bodies among patients with sickle cell
disease have been described as “fish vertebrae” (smooth biconcave deformity secondary
to marrow hyperplasia with resultant osteoporosis), H-shaped (an abrupt cup-like lesion
due to central infarction and collapse), and tower vertebrae (an increase in vertical height
possibly due to compensatory growth or marrow hyperplasia) (Marlow et al 1998).
This patient has evidence of “fish vertebrae.” It would be difficult to rule out
osteomyelitis radiographically, although osteomyelitis occurs much less frequently than
vaso-occlusive disease in these patients, and is more common in long bones
(Ntagiopoulos et al 2007, Madani et al 2007).
4. What would you recommend next for this patient?
If clinically indicated (i.e., would change patient management), it may be
appropriate to perform a high resolution CT scan of the thorax and abdomen to assess the
extent of chronic or acute changes caused by sickle cell anemia. MRI may be indicated
to further study any bone changes.
5. Is the use of this test/procedure appropriate?
A radiograph of the thorax is appropriate for initial assessment of back pain in a
woman with sickle cell anemia.
6. Is(are) there any alternate test(s)?
Alternatively, a CT or MRI could be performed, but would be more expensive.
Rib infarcts are best studied using bone scintography (Leon and Stark, 1998).
Pam Leece, Student #4346746
7. How would you explain to the patient about the possible risks and benefits of this
test?
The benefits of chest radiograph is that it is relatively inexpensive, widely
available, as well as being fast and easy. The risk is exposure to radiation, and that more
information may be needed by using other tests (e.g., CT to further study lungs).
8. What is the cost of this test?
(H= technical component, P= professional component)
Source: Ontario Ministry of Health and Long-Term Care Schedule of Benefits for
Physician Services under the Health Insurance Act, April 1, 2008
http://www.health.gov.on.ca/english/providers/program/ohip/sob/physserv
/physserv_mn.html
References
Leong CS, Stark P. Thoracic manifestations of sickle cell disease. J Thorac Imaging.
1998 Apr;13(2):128-34.
Madani G, Papadopoulou AM, Holloway B, Robins A, Davis J, Murray D.
The radiological manifestations of sickle cell disease. Clin Radiol. 2007 Jun;62(6):52838. Epub 2007 Mar 26.
Marlow TJ, Brunson CY, Jackson S, Schabel SI. "Tower vertebra": a new observation in
sickle cell disease. Skeletal Radiol. 1998 Apr;27(4):195-8.
Ntagiopoulos PG, Moutzouris DA, Manetas S. The "fish-vertebra" sign. Emerg Med J.
2007 Sep;24(9):674-5.