DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
FINAL DIAGNOSES:
1. Splenic sequestration.
2. Possible delayed transfusion reaction.
3. Fever.
4. Sickle cell crisis.
BRIEF HISTORY AND HOSPITAL COURSE: This is a (XX)-year-old female with known sickle cell anemia, on chronic transfusion, who presents with high spiking fever, back pain, and headache. On admission physical examination, she had markedly enlarged spleen 7 cm below the costal margin. Her initial laboratory studies revealed a white count of 5800, hemoglobin of 9.8, hematocrit of 29, and a platelet count of 94,000 with a differential of 39 segs, 8 bands, 45 lymphs, and 8 monos. Type and cross and direct Coombs were performed, and direct Coombs was weakly positive.
In light of her high spiking fever and her constellation of symptoms, blood cultures were drawn, and she was empirically started on IV antibiotics with cefuroxime. Over the next couple of days, she continued with high spiking fever, intermittent headache, back pain, and abdominal pain. Her urine was found to be positive for blood without any red blood cells noting hemoglobinuria. Her hemoglobin dropped to 6.8, and her platelet count dropped to 54,000. The patient was transfused packed red blood cells on MM/DD/YYYY and MM/DD/YYYY. She continued to have high spiking fever to 103 and 104 despite IV antibiotics. Blood cultures remained negative. Repeat Parvovirus titer and EBV titers were performed. Parvovirus was found to be negative, and EBV panel was significant for a past infection. Abdominal ultrasound to evaluate her abdominal pain revealed a spleen, which was 16.4 cm with no definite infarct and being homogeneous.
Of note, during her hospitalization, she developed a significant nosebleed, which stopped with pressure. Slowly, her abdominal pain improved. Her spleen size improved after transfusion and slowly got smaller by about 2 cm. She was noticed, as her hospitalization went on, to have mildly enlarged, tender liver about 2 cm below the costal margin. Her hemoglobin stabilized at 9.8. Because of continued spiking fevers despite IV cephalosporin, she was started on Zithromax.
Over the next several days, her back pain, headache, and abdominal pain significantly improved and she became afebrile. On the day of discharge, abdominal pain had improved. She was afebrile. Her spleen was about 3 to 4 cm below the costal margin and liver was approximately 2 cm below the costal margin. Her hemoglobin rose to 10 with a hematocrit of 29.8 and a platelet count of 168,000 with a white count of 4700. Followup hemoglobin electrophoresis revealed hemoglobin A1 of 81.4%, hemoglobin S of 8.8%, and hemoglobin A2 of 2%. CMV titers, which were sent, also revealed a past infection.
Initial chest x-ray, during her hospitalization, showed no acute cardiopulmonary disease. No bone lesions noted. Ultrasound of the abdomen revealed splenomegaly. Repeat chest x-ray showed no evidence of focal consolidation.
SIGNIFICANT FINDINGS: As noted above.
PROCEDURES AND TREATMENTS DONE: Transfusion of packed red blood cells, IV hydration, and IV antibiotics.
DISCHARGE CONDITION: The patient was stable.
DISCHARGE DIET: Regular.
PHYSICAL ACTIVITY: As tolerated.
DISCHARGE MEDICATIONS: Zithromax 200 mg p.o. daily for an additional two days, to restart Desferal subcutaneous infusion daily.
DISCHARGE INSTRUCTIONS: Follow up in the pediatric hematology-oncology clinic in one week.
