Sickle-Cell Disease

Description

Complications

There is still no cure for sickle-cell disease other than experimental transplantation procedures, but treatments for complications of sickle cell have prolonged the lives of many patients who are now living into adulthood.

Pain in the Acute Sickle-Cell Crisis

The hallmark of sickle-cell disease is the sickle-cell crisis (also sometimes known as a vaso-occlusive crisis), which is an episode of pain. It is the most common reason for hospitalization in sickle-cell disease. The pattern may occur as follows:

• In general, the risk for a sickle-cell crisis is increased by any activity that boosts the body's requirement for oxygen, such as illness, physical stress, or being at high altitudes. In more than half of episodes, however, the trigger is unknown.
• Episodes typically begin at night and last from three to 14 days, accelerating to a peak over several days and then declining.
• The pain is typically described as sharp, intense, and throbbing. Severe sickle cell pain has been described as equivalent to cancer pain and more severe than postsurgical pain. Shortness of breath is common.
• Pain most commonly occurs in the lower back, leg, hip, abdomen, or chest, usually in two or more locations. Episodes usually recur in the same areas. Pain in the bones (usually occurring symmetrically on both sides) is common because blood obstruction can directly damage bone and because bone marrow is where red blood cells are manufactured.
• The liver may become enlarged, causing pain in the upper right side of the abdomen. Liver involvement may also cause nausea, low-grade fever, and increasing jaundice.
• Males of any age may experience prolonged, often painful erections, a condition called priapism.

Episodes cannot be predicted and they vary widely among different individuals. In one study, nearly 40% of patients reported no painful episodes over a five-year period. About 5% of patients experienced severe and frequent episodes (more than three a year). They sometimes become less frequent with increasing age. Generally, people can resume a relatively normal life between crises. Most patients are pain free between episodes although pain can be chronic in some cases.

General Guidelines for Managing a Sickle-Cell Crisis. The basic objectives for managing a sickle-cell crisis are control of pain and rehydration by administration of fluids. Oxygen is typically given for acute chest syndrome. Effective pain medications are available to help reduce the severe pain of sickle-cell crises.

Accurate and continually updated assessment of pain determined by patient input and participation is at the crux of effective care for children with sickle-cell disease. Often, however, patients are not given the treatment they require. According to one study, for example, 71% of children were inadequately treated for their pain. Possible reasons for this are as follows:

• Many patients, their families, and even physicians are hesitant to use opioids aggressively because of fear of addiction. This fear, however, is nearly always unwarranted. Addiction occurs in only about 1% to 3% of patients with sickle cell disease who are taking opioids.
• Many physicians do not understand the nature of sickle-cell pain. For example, early phases of sickle-cell crisis can cause severe pain before test results confirm a diagnosis of a crisis. In such cases, health professionals may question the patient's self-reporting and withhold appropriate pain medication.
• Patients may behave normally (e.g., talking on the phone, sleeping) and not appear to be in pain, but have actually developed coping behaviors to allow them to function in spite of severe pain.
• Children and adults report pain differently, with children tending to report less pain than they feel. (One way of determining the severity of pain that a child feels is to show pictures of faces demonstrating degrees of pain and asking the child to point to the one that best expresses his or her experience.)
• Many patients use emergency rooms of large hospitals for treating acute pain. Waiting times are long and there is no single health care provider who knows the patient and can offer consistent assessment and management of pain.

Adult patients and parents of children with the disease should insist on aggressive pain-relief treatment. If physicians show any reluctance to administer medications after the onset of pain, patients or caregivers should not hesitate to seek a more responsive health care professional.

Opioids. For severe pain, the patient must be hospitalized and treated with strong painkillers, usually opioids. Opioids are generally given orally to adults and adolescents and intravenously to children. Nevertheless, there are exceptions. Older patients with severe pain may also require intravenous administration. Studies are also suggesting that oral medications may be effective in children.

• Morphine (Dilaudid) is often used for frequent or prolonged episodes of pain. Unfortunately, its effectiveness is not as long-lasting in sickle cell patients as it is in other patients with severe pain, such as those with cancer.
• The opioid meperidine (Demerol) is also used for sickle-cell crises. Meperidine is not as powerful as morphine, however, and, if used for prolonged periods, may cause twitches, tremors, and disturbed mental states including seizures.
• Some newer synthetic opioids (fentanyl or hydromorphone) that have a rapid onset and possibly fewer side effects than morphine. Fentanyl can be applied using a patch, which may help some patients who have difficult receiving intravenous agents. It takes 12 hours to be effective, however.
• Oral agents, such as methadone, oral morphine, codeine, and oxycodone, are useful for home management of chronic pain and for transitional treatments between the hospital and home. Tramadol (Ultram) is a potent oral painkiller that has opioid-like properties but is not as addictive. (Dependence and abuse have been reported, however.) It may be very useful for sickle cell patients who need painkillers outside the hospital. It has minimal effects on respiratory function and has a low potential for addiction.

The most dangerous side effect of high doses of opioids, especially morphine, is depression of breathing function. This can occur some time after the drug has been administered, and so patients must be watched closely and monitored during treatment.

Other side effects of opioids are vomiting and nausea, itching, and problems urinating. If the patient vomits or becomes nauseated, the physician may administer prochlorperazine (Compazine). Devices have been developed to allow patients to administer their own painkillers as needed.

Anti-Inflammatory Drugs. Because of the potentially serious side effects of opioids, physicians are constantly searching for safer and easier ways of reducing the severity of pain of sickle-cell crises. Because experts believe that inflammation is a major contributor to the pain of sickle-cell disease, drugs that reduce inflammation are being studied.

• Prescription-strength NSAIDs, including diflunisal (Dolobid) or ketorolac (Toradol), are under investigation. Ketorolac may be particularly helpful in relieving bone pain, and may be effective for individuals who cannot tolerate opioids. In one study, it was superior to meperidine and had fewer side effects. Studies have suggested, however, that when used as first-line therapy in an acute crisis, ketorolac is effective only in about half of episodes.
• Corticosteroids are powerful anti-inflammatory agents that are commonly used to treat pain caused by inflamed muscles and joints. Such drugs include methylprednisolone (Medrol) and dexamethasone (Decadron, Hexadrol). Studies are reporting that using these drugs along with opioids may help some sickle-cell patients. In one study, children who were given methylprednisolone and morphine had a shorter period of severe pain and required less morphine to control the pain than those given morphine alone. These children, however, had more recurrent attacks after medication was withdrawn than those treated with opioids alone. Because steroids can suppress the body's infection fighters, they should not be given to patients with bacterial infections or any serious medical complication.

Epidural Anesthesia. An epidural analgesia (injection of an anesthetic into the spinal fluid) may be very effective for pain that is unresponsive to the usual therapies.

Stimulants. Some physicians report that stimulants, such as methylphenidate (Ritalin) and dextroamphetamine, may enhance the pain-killing effects of opiates and counteract the sleepiness they cause. Clinical studies are needed to confirm possible benefits, however.

Surfactants. Poloxamer 188 (Flocor, RheothRx) is an investigative synthetic compound known as a surfactant. It coats damaged blood cells, allowing them to slip over one another, thereby improving blood flow and oxygen delivery. Late clinical studies have been promising. A 2001 study reported that it reduced the duration of the crisis from 141 to 133 hours (which is still a long time). It was even more effective in children (reducing it to 21 hours) and in patients taking hydroxyurea (16 hours).

Cordox. A natural sugar-based compound called fructose-1,6-diphosphate, FDP (Cordox) reduces inflammation and protects cells against the oxygen-depriving effects of sickling. This agent also is investigative. Studies are indicating that it relieves vaso-occlusive pain. In one study, taking only one dose reduced pain scores. It is not addictive and does not appear to have significant adverse effects.

Acute Chest Syndrome

Acute chest syndrome (ACS) occurs when the lungs are deprived of oxygen during a crisis. It can be very painful, dangerous, and even life threatening. It is a leading cause of illness among sickle-cell patients and is the most common condition at the time of death. At least one whole segment of a lung is involved and the following symptoms may be present:

• Fever of 101.3 F degrees (38.5 C) or above.
• Rapid or labored breathing.
• Wheezing or cough.
• Acute chest pain often lasts for several days. In about half of patients, severe pain develops about two and a half days before there are any signs of lung or chest abnormalities. Acute chest syndrome is often accompanied by infections in the lungs, which can be caused by viruses, bacteria, or fungi. Pneumonia is often present.
• A dull, aching pain usually follows, which most often ends after several weeks, although it may persist between crises.

Causes of Acute Chest Syndrome. The two primary causes of acute chest syndrome are one or a combination of the following:

• Infection. Infection from viruses or small atypical organisms (Chlamydia and Mycoplasma) is the most common causes of the oxygen deprivation that leads to acute chest syndrome.
• Blockage of blood vessels. Blockage in the blood vessels (called infarction) that cuts off oxygen in the lungs is another important cause of acute chest syndrome. Blockage may be produced by blood clots or fat embolisms. (Fat embolisms are particles formed from fatty tissue in the bone marrow that enter and travel through the blood vessels.)

In about 45% cases, the cause cannot be established. Some cases of acute chest syndrome may result from treatments of the crisis, including from administration of opioids (which reduce oxygen) or excessive use of intravenous fluids. Other lung diseases may also trigger ACS.

Severity of Acute Chest Syndrome. The mortality rates for ACS are 1.8% in children and 4.3% in adults. The syndrome and its long-term complications are the major causes of death in older patients. In one major 2000 study, 13% of patients with acute chest syndrome needed mechanical ventilation for supporting their breathing, 11% had some neurologic symptoms, and it was fatal in 9% of adult patients. The condition is four times more deadly in adults than in children. The longer a patient survives, the greater is the damage done by repetitive sickle-cell crises in the chest and lungs.

The following destructive effects can occur:

• Infarction or severe infection that cause the acute chest syndrome can be fatal.
• Lack of oxygen in the chest or in the bones cause severe pain.
• Damage in the chest area increases susceptibility to invading infectious agents, even agents that are ordinarily not harmful. Infections frequently clear up if they are limited to small areas of the lung, but if they spread, they can progress very quickly and become life threatening.
• Lung damage over time can lead to obstruction in the airways in lungs, causing asthma-like conditions.

Initial Management. Acute chest syndrome can be fatal and must be treated immediately. Basic treatments include the following:

• Supplementary oxygen. (This is critical and life saving.)
• Administration of fluids. (Overhydration should be avoided to reduce the risk of fluid in the lungs.)
• Pain-relievers.
• Use of bronchoscopy to identify infection. This is a diagnostic procedure involving insertion of a tube into the lower airways.

Other Treatments. Other treatments include:

• High-dose intravenous corticosteroids, usually, dexamethasone, may hasten recovery from acute chest syndrome and reduce the duration of hospitalization. They are also important if fat embolisms develop.
• Bronchodilator therapy (drugs that open the air passages). This treatment can be effective for some patients who are wheezing or have obstructed lung function.
• Antibiotics. Those used should specifically target the organisms (e.g., Chlamydia, Mycoplasma) that commonly trigger acute chest syndrome. (Such antibiotics include erythromycin, azithromycin, clarithromycin, and various tetracyclines.)

Transfusions. These are important early on for rapid improvement in severe cases, especially if fat embolisms have developed.

Pneumonia and Other Infections

Infections are common and an important cause of severe complications in sickle cell patients. Before early screening for sickle-cell disease and the use of preventive antibiotics in children, 35% of sickle-cell infants were lost to infections. Fortunately, with screening tests for sickle cell now required for newborns in most states and with the use of preventive antibiotics in babies who are born with the disease, this terrible mortality rate has dropped significantly.

Infections in Infants and Toddlers with Sickle-Cell Disease. The most common organisms causing infection in children with sickle-cell disease are the following:

• Streptococcus pneumoniae (which can cause blood infections or meningitis).
• Haemophilus influenza (which is a cause of meningitis).

Such infections pose a grave threat to infants and very young children with sickle-cell disease. They can progress to fatal pneumonia with devastating speed in infants, and death can occur only a few hours after onset of fever. The risk for pneumococcal meningitis, a dangerous infection of the central nervous system, is also significant.

Infections in Children and Adults. Infections are also common in older children and adults with sickle-cell disease, particularly respiratory infections such as pneumonia, kidney infections, and osteomyelitis, a serious infection in the bone. The organisms causing them, however, tend to differ from those in young children. The incidence of pneumococcal infections decrease and those caused by other bacteria increase, including the following:

• Chlamydia and Mycoplasma pneumoniae. These are the important agents in acute chest syndrome (see above).
• Gram-negative bacteria. This group of agents mostly infects hospitalized patients and can cause serious pneumonias and other infections.

General Approach to Treating Infections. Fever in any sickle cell patient should be considered an indication of infection. Temperatures over 101 F in children warrant a call to the physician. Adults with sickle cell should call the doctor if they have a have fever over 100 F and any signs of infection including chest pain, productive cough, urinary problems, or any other symptoms. Some approaches for treating infections are as follows:

• Hospitalization for Infections. When sickle-cell patients develop infections, they are nearly always hospitalized immediately and treated with intravenous or high dose injections of antibiotics in order to prevent septicemia, the dangerous spread of the infection throughout the body. Antibiotics called cephalosporins (e.g., cefotaxime [Claforan], ceftriaxone [Rocephin] or cefuroxime [Ceftin]) are typically used. Repeated hospitalizations are very disruptive for both children and adults. Studies have found that older children whose fever is below 38.5 C (101 F) and who have no serious infection or other complications may not need hospitalization. Children who have indications of serious complications of infection (higher fevers, pain, a history of pneumonia, and signs of dehydration) should remain in the hospital.
• Treatment of Osteomyelitis. If osteomyelitis, an infection in the bone, occurs, a six-week antibiotic course is needed, most of it intravenous. An accurate diagnosis of osteomyelitis is sometimes difficult to make, because bone damage from sickling can cause similar symptoms. It should be strongly considered in children with signs of pain and swelling in the legs, a high white blood cell count, high fever, and high levels of a test that measures so-called sedimentation rates. It is important, however, to confirm the presence of an actual infection before administering antibiotics, because the antibiotic treatment required for osteomyelitis is so intensive and prolonged. The most common cause of osteomyelitis in children is Salmonella.
• Treatment of Urinary Tract Infections. Urinary tract infections may be difficult to manage and can be a serious problem for pregnant women with sickle-cell disease. Physicians should take a urine culture before beginning antibiotic treatment and another culture one to two weeks after treatment to be sure the infection has cleared up.

Using Antibiotics for Prevention. Preventive (prophylactic) antibiotics are the best approach for protection against pneumonia and other serious infections among children with sickle-cell disease. Children diagnosed with sickle cell are given daily antibiotics, usually penicillin, unless a child is allergic and then alternatives are available. The ideal age for stopping preventive antibiotics is not yet clear, although the risk for serious infections are relatively lower after age five.

Unfortunately, studies suggest that children who are on public medical insurance often receive inadequate treatment. In addition, many patients stop taking their antibiotics or the parents stop giving them to their children. Physicians are also concerned about developing bacterial resistance to common antibiotics and researchers warn that patients might experience break-through infections as resistance becomes more frequent.

Vaccinations. Everyone with sickle-cell disease should have complete regular immunizations against all common infections. Children should have all routine childhood vaccinations, and the following are important for everyone with sickle-cell disease:

• Vaccination against Haemophilus influenza (the major cause of childhood meningitis).
• Influenza vaccinations ("flu vaccines") every winter.
• Pneumococcal vaccine. All sickle-cell patients should be vaccinated with the pneumococcal vaccine. Protection lasts for over six years in most people. Children with sickle-cell disease should receive three doses of the pneumococcal conjugated vaccine (Prevnar) between two and six months of age, followed by two doses at age one, and then vaccinations at age two, five, and every 10 years afterward. (Some experts recommend every five years rather than every 10 years.)
• Yearly tuberculosis test.
• Hepatitis B vaccine. (Anyone starting transfusion therapy should receive it if they had not been immunized as children.)

Other Effects on the Lungs

Impaired Lung Function. A 2003 study observed impaired lung function starting at very early ages (five and over) in children with sickle cell. Although not outside the normal range, such signs of abnormalities in the airways of the lungs may warrant early treatments for obstructive or restrictive lung disease (which are similar to those for asthma patients).

Pulmonary Hypertension.Pulmonary hypertension is a serious condition that develops if blood pressure in the lungs increases, in some cases to a dangerous level. Some experts believe it is an important and often unrecognized complication and cause of death in of sickle cell disease. The primary symptom is shortness of breath, which is often severe. Pulmonary hypertension can be very serious and life threatening in the short- and long-term. If pulmonary hypertension develops suddenly it can cause respiratory failure, which is life threatening. Over time, pulmonary hypertension may cause a condition called cor pulmonale, in which the right side of the heart increases in size. In some cases, this enlargement can lead to heart failure. Prostaglandins, bosentan (an endothelin receptor antagonist), and other agents are used to treat this condition. L-arginine, which converts to nitric oxide, is showing promise.

Stroke

After acute chest syndrome, stroke is the most common killer of patients with sickle-cell disease who are older than three years old. Between 8% and 10% of patients suffer strokes, typically at about age seven. Transfusions are proving to prevent a first stroke as well as recurrence. Strokes are usually caused by blockages of vessels carrying oxygen to the brain. Sickle-cell patients are also at high risk for stokes caused by aneurysm, a weakened blood vessel wall that can rupture and hemorrhage. Multiple aneurysms are common in sickle-cell patients, but they are often located where they can be treated surgically. (Some experts believe that any patient who has neurologic symptoms indicating a potential stroke should undergo angiography, an invasive diagnostic technique useful for detecting aneurysms.)

Transfusions for Prevention of Stroke. Compelling data show that regular (monthly) blood transfusions can reduce the risk of a first stroke by 90% in high-risk children. The objective of such transfusions is to reduce hemoglobin S concentrations to less than 30% of total hemoglobin. Studies indicate that as many as 90% of patients who have experienced a stroke do not experience another stroke after five years of transfusions. Some centers are now administering transfusion therapy indefinitely. Complications from this treatment, however, can be considerable and more studies are needed to determine when transfusions can be safely stopped. In centers where transfusions are stopped after three years (which is still in the majority of centers), strokes occur in about of half of children.

Unfortunately, no tests can definitely determine which individual children are at highest risk for a first stroke and, therefore, would be candidates for ongoing transfusions. The following are diagnostic tools currently used or under investigation:

• Transcranial Doppler (TCD) ultrasonography measures the speed of blood flow in the brain and is the most sensitive method to date for identifying children at risk for stroke. It is still not highly accurate, and many physicians are concerned about giving continual transfusions to every sickle-cell patient whose ultrasounds indicate risk.
• The use of follow-up magnetic resonance imaging (MRI) to detect small blockages in blood vessels may help confirm high risk in patients identified by TCD ultrasound. A 2001 study indicated that giving transfusion therapy to children who showed abnormalities after an MRI reduced the risk for stroke.
• Researchers are also beginning to uncover possible genetic markers that may eventually be used to help identify sickle cell patients at higher risk for stroke.

Until diagnostic tests can be more precise, or effective alternative treatments to transfusions exist, patients and their caregivers and physicians must make the best decisions they can.

Anticoagulation.Researchers have investigated anti-blood clotting agents, such as aspirin and heparin, for preventing stroke, but their use is controversial, and their effects on children are unclear and understudied. For example, one study on children with stroke from causes other than sickle cell report that this approach is safe but may not have offer any significant protection.

Anemia

Anemia is a significant characteristic in sickle-cell disease (which, in fact, is commonly referred to as sickle-cell anemia).

Hemolytic Anemia and Aplastic Crises. Because of the short life span of the sickle red blood cells, the body is often unable to replace red blood cells as quickly as they are destroyed. This causes a particular form of anemia called hemolytic anemia. Episodes of hemolytic anemic are called aplastic crises, which are usually managed well with transfusions. In about 80% of cases, aplastic crises are triggered by a virus called human parvovirus B19. There is some evidence that the virus increases the risk for neurologic complications, including encephalitis and stroke. (This virus is common and usually harmless in healthy individuals.)

Chronic Anemia. Chronic anemia reduces oxygen and increases the demand on the heart to pump more oxygen-bearing blood through the body. Eventually, this can cause the heart to become dangerously enlarged, with an increased risk for heart attack and heart failure. Folic acid and possibly iron supplements are often given to help treat the anemia that occurs in patients with sickle-cell disease. (Patients who are given multiple transfusions may experience iron overload, and iron supplements should be avoided in such cases. Also of note, folic acid can mask pernicious anemia, which is caused by deficiency of vitamin B12 and is more common in African Americans than other populations.)

Problems in the Kidney

The kidneys are particularly susceptible to damage from the sickling process. Persistent injury can cause a number of kidney disorders, including infection. Problems with urination are very common, particularly uncontrolled urination during sleep. Patients may have blood in the urine, although this is usually mild and painless and resolves without damaging consequences. Kidney failure is a major danger in older patients and accounts for 10% to 15% of deaths in sickle-cell patients. Renal medullary carcinoma is an aggressive, rapidly destructive tumor in the kidney that is rare but can occur as a result of sickle cell.

Treatment for Kidney Problems. Kidney damage in sickle cell patients can cause bleeding into the urine. Mild episodes can usually be treated with bed rest and fluids. Severe bleeding may require transfusions. ACE inhibitors are drugs commonly used to control high blood pressure and are proving to be important for preventing hypertension and kidney failure in sickle-cell patients. Such drugs include captopril (Capoten), enalapril (Vasotec), quinipril (Accupril), benazepril (Lotensin), and lisinopril (Prinivil, Zestril).

Problems in the Genital Tract

A reported 38% to 42% of males, including children, with sickle-cell disease suffer from priapism, which are prolonged and painful erections. If priapism is not treated, partial or complete impotence can occur in 80% of cases.

Treatment for Priapism. Priapism, prolonged and sometimes painful erections, must be treated to prevent partial or complete impotence, which can result from erections that last several hours to days. Exchange transfusions may be used to reduce the hemoglobin S and sickling that cause this condition. Drugs used to prevent priapism include terbutaline and phenylephrine, which help restrict blood flow to the penis. Hormonal treatments, such leuprolide (Lupron) and diethylstilbestrol, may prevent repetitive and prolonged episodes of priapism in severely affected teenage boys with sickle-cell disease. A surgical procedure that implants a shunt to redirect blood flow is sometimes performed. Inflatable penile implants may help maintain potency without causing priapism.

Problems in the Liver

Enlargement of the liver occurs in over half of sickle-cell patients, and acute liver damage occurs in up to 10% of hospitalized patients. Because sickle-cell patients often need transfusions, they have been at higher risk for viral hepatitis, an infection of the liver. This risk, however, has decreased since screening procedures for donated blood have been implemented.

Gallbladder Disease

About 30% of children with sickle-cell disease have gallstones, and, by age 30, 70% of patients have them. In most cases, gallstones do not cause symptoms for years. When symptoms develop, patients may feel overly full after meals, have pain in the upper right quadrant of the abdomen, or have nausea and vomiting. Acute attacks can be confused with a sickle-cell crisis in the liver. Ultrasound is usually used to confirm a diagnosis of gallstones.

Treatment of Gallbladder Disease. Children with sickle-cell disease have an increased risk for gallstones. However, if they have no symptoms, no treatment is usually necessary. If the have recurrent or severe pain from gallstones, the gallbladder may need to be removed. Minimally invasive procedures (using laparoscopy) reduce possible complications. [See Well-Connected Report # 10 Gallstones.]

Damaged Spleen

The spleen of most adults with sickle-cell anemia is nonfunctional due to recurrent episodes of oxygen deprivation that eventually destroys it. Injury to spleen causes abnormalities in immune function and increases the risk for serious infection. A very serious anemic condition called acute splenic sequestration crisis (sudden spleen enlargement) can occur if the damaged spleen suddenly enlarged from trapped blood.

Treatment for Complications in the Spleen. The spleen is often removed (splenectomy) in children who have one or two acute splenic sequestration crises. Transfusion therapy is an alternative for preventing acute splenic sequestration in high-risk patients. At this time there are no studies comparing overall survival and benefits between the two approaches.

Problems in the Bones and Joints

In some children with sickle-cell disease, excessive production of blood cells in the bone marrow causes bones to grow abnormally, resulting in long legs and arms or misshapen skulls. Sickling that blocks oxygen to the bone can also cause bone loss and pain. Sickling that affects the hands and feet of children causes a painful condition called hand-foot syndrome. A condition called avascular necrosis of the hip occurs in about half of adult sickle cell patients when oxygen deprivation causes tissue death in the bone. Eventually adult patients may require surgery to remove diseased and dead bone tissue. Joint replacement may be required in severe cases. X-rays are not very useful for detecting early disease in the bones. MRI may be important. Ultrasound is also a helpful tool in diagnosing and treating these abnormalities.

Leg Sores and Ulcers

Leg sores and ulcers occur in up to 10% of sickle-cell patients and usually affect patients older than 10 years. They are difficult to treat, and, at this time, simple treatment with a moist dressing provides the best results. To treat mild ulcers, the leg should be gently washed with cotton gauze soaked in mild soap or a solution of one tablespoon of household bleach to one gallon of water. A dressing soaked in diluted white vinegar may be applied every three to four hours.

More severe ulcers require debridement, which is the removal of injured tissue until only healthy tissue remains. Debridement may be accomplished using chemical (enzymes), surgical, or mechanical (e.g. irrigation) means. Hydrogels (Nu-Gel, Intrasite Gel, Scherisorb, Clearsite, Duoderm, Geliperm) are helpful in healing ulcers and are noninvasive and soothing. Topical antibiotics, saline or zinc oxide dressings, or cocoa butter or oil are also used depending on severity. The leg should be elevated and bed rest for a week or more is sometimes required for severe ulcers.

Skin grafts and transfusions have been helpful in some extreme cases. In a promising 2002 study administering arginine butyrate for many weeks improved ulcer healing by ten-fold. (This agent is also under investigation for other beneficial effects in sickle-cell patients.)

Problems in Mental Functioning

In one 2000 study of adults with sickle cell disease, 22% suffered from neurologic complications. Stroke is a major factor in such problems. Sickle-cell disease also poses a high risk for mild mental deficiency from low levels of oxygen in brain tissue or from silent strokes, even in the absence of a major stroke. Such deficiencies can impair learning and behavior but may not even show up on normal imaging tests and thus may not be attributed to sickle-cell disease. Some experts recommend clinical trials using brain scans to detect the location of small injuries and try to determine whether they might be causing mental or behavioral problems that are inaccurately believed to be unrelated to the disease.

The Pregnant Woman with Sickle Cell

Women with sickle-cell disease who become pregnant are at higher risk for complications, but serious problems have dropped significantly over the past decades. A 2001 study reported a higher risk for premature birth and low birth weight in the baby, and a higher risk for infections and hospital visits in the mother after delivery. Pain crises occur in nearly half of women and nearly 60% required transfusions. The study also reported, however, that, in general, the outcome for pregnancy is favorable. Still, pregnancy during sickle cell is high-risk and carries a mortality rate of about 1%.

Treatment During Pregnancy. Women who are pregnant should be treated at a high-risk clinic. They should take folic acid in addition to multivitamins and iron. Standard treatment is given for sickle-cell crises, which may occur more frequently during pregnancy. The benefits of transfusions to prevent crises during pregnancy are not yet clear and experts recommend them only for women who experience frequent complications during pregnancy.

Other Medical Complications

Older children and adult patients with sickle cell are subject to other medical problems, including impaired physical development, gum disease, and scarring and detachment of the retina.