Case 57

A Child with Pneumonia

John A. Koepke

A 12-year-old African-American male child was admitted to the hospital through the
emergency room because of severe illness marked by high fever [1038F (39.68C)] and
rapid, shallow breathing. Physical examination indicated consolidation of the left lower
lung fields where no breath sounds could be auscultated. Examination of the abdomen
revealed that the liver was enlarged, but the spleen could not be palpated. The patient
had several healed scars and open sores on his ankles. Portable x-ray examination of
the chest showed consolidation of the left lower lobe of the lung. Pulse oximetry on
room air was 87%, improving to 95% while receiving supplemental oxygen (3-L
nasal prong).
A blood sample drawn in the emergency room provided the following results:

Reference
Value, Interval, Reference
Conventional Conventional Value, Interval,
Analyte Units Units SI Units SI Units
WBC 28  103/mL 3.2– 9.8 3.2 –9.8  109/L 3.2 – 9.8
RBC 3.88  106/mL 4.50– 5.70 3.88  1012 L 4.50 – 5.70
Hemoglobin 10.0 g/dL 13.6– 17.2 110 g/L 136 – 172
MCV 82 fL 80 – 110 Same
RDW 23 11 – 14.5 Same
Reticulocyte % 8% 0.5– 1.5 0.08 fraction 0.005 – 0.015
Platelet count 658  106/mL 140 – 440 658  109/L 140 – 440
Bilirubin, total 2.0 mg/dL 0.3– 1.1 34.2 mmol/L 5.1 – 18.8
LDH 334 U/L 100 – 250 5.7 mkat/L 1.7 – 4.3
Haptoglobin 10 mg/dL 27 – 220 100 mg/L 270 – 2200

Review of the peripheral blood film showed poikilocytosis with crescent-shaped

erythrocytes (Fig. 57.1). There was a granulocytosis with a marked left shift, that is,
with many immature granulocytes in the circulation. Many granulocytes contained
toxic granulations and had Döhle bodies. Chemical urinalysis showed proteinuria, but
screening tests for urinary tract infection (i.e., nitrite and leukocyte esterase) were nega-
tive. Examination of stained sputum showed many Gram-positive cocci in pairs and short
chains, sometimes within granulocytes. Sputum culture grew Streptococcus pneumoniae,

Tietz’s Applied L aboratory Medicine, Second Edition. Edited by Mitchell G. Scott, Ann M. Gronowski, and
Charles S. Eby
Copyright # 2007 John Wiley & Sons, Inc.

411
412 Case 57 A Child with Pneumonia

Figure 57.1 Peripheral smear showing sickle cells (black arrows) and target cells (white arrows).

which was consistent with the initial Gram stain of the sputum. The diagnosis of
acute pneumonia was made based on the laboratory and radiological findings, and the
patient was treated with antibiotics for bacterial (pneumococcal) pneumonia. Additional
tests were performed to evaluate his anemia. He did well and was discharged from the
hospital in 5 days.

Differential Diagnosis

The combination of anemia and pneumococcal pneumonia in an African-American child

directs attention to consideration of another underlying disorder possibly involving a
hemoglobinopathy. The findings of proteinuria and mild hepatomegaly without apparent
splenomegaly or lymphadenopathy also provide the clinician with leads that can be
pursued with appropriate laboratory examination.
Laboratory investigation of anemia begins with an automated complete blood count
(CBC) that differentiates anemias into normocytic (MCV, 80– 100 fL), microcytic
(MCV, ,80 fL), or macrocytic (MCV, .100 fL) types. Normocytic anemia, such as
this case showed, mandates examination of the peripheral blood smear for unusual or
abnormal erythrocytes that demonstrate microcytosis, hypochromia, spherocytosis, aniso-
cytosis, poikilocytosis, or presence of target or sickle cells. Howell –Jolly bodies in some
erythrocytes indicate a nonfunctioning spleen that can result from sickle cell disease.
Multiple episodes of crisis cause splenic ischemia and infarction, finally culminating in
splenic fibrosis and atrophy (i.e., autosplenectomy).
A reticulocyte count is very useful in differentiating hemolytic anemias with
increased erythropoiesis from nonhemolytic anemias in which erythrocyte production is
diminished. The reticulocyte count is elevated in most hemolytic anemias [in this case,
the absolute reticulocyte count (RBC  reticulocyte %) was 310  103/mL (reference
range 24 –84)], although a normal or low reticulocyte count may occur in aplastic crises.
The diagnosis of hemolytic anemia was made on the basis of a moderate anemia
coupled with an elevated reticulocyte count. Because the patient was African-American,
sickle cell disease (with a prevalence of 1 in 600 African-Americans) was at the top of the
 Differential Diagnosis 413

list of possible diagnoses. In this patient, the sickle cell solubility test was positive. This
test checks for the decreased solubility of reduced sickle hemoglobin (HbS) in a specially
constituted buffer solution causing increased turbidity that can be distinguished by visual
inspection when compared to control hemoglobin incubated under similar conditions.
Glucose-6-phosphate dehydrogenase (G6PD) deficiency should also be considered in
the differential diagnosis. The gene for G6PD is carried on the X chromosome, and con-
sequently G6PD deficiency is a sex-linked disorder. Its incidence in African-American
males is roughly 1 in 8. Erythrocytes of these individuals contain levels of G6PD that,
although low, usually maintain an adequate reserve of reduced glutathione to prevent oxi-
dation of hemoglobin. However, exposure to oxidizing substances (e.g., primaquine for
prophylaxis of malaria, nitrofurantoin for urinary tract infection, or fava beans) or an
acute febrile illness may overwhelm the fragile system operating with marginal levels
of G6PD and lead to phagocytosis of red cells containing denatured hemoglobin (Heinz
bodies). In interim periods, the erythrocytes of patients deficient in G6PD survive
normally. G6PD deficiency is detected with a screening procedure followed by quantitat-
ive assay for specific enzymatic activity. The G6PD screening test was negative in this
patient, indicating normal G6PD activity.
African-American patients may be afflicted with thalassemia or thalassemia – sickle
cell disease, and therefore the possibility of these conditions must not be ignored. Hemo-
globin electrophoresis plus measurement of the concentrations of fetal hemoglobin and
hemoglobin A2 are necessary to make these diagnoses. The exact delineation of the
various kinds of thalassemia can at times be quite difficult, and family studies as well
as more sophisticated laboratory studies (e.g., isoelectric focusing method of separating
hemoglobin types, direct amino acid sequencing, a- and b-hemoglobin chain synthetic
ratios, a-globin gene deletion and b-globin coding and noncoding mutations by DNA
analysis) may be required in certain cases.1,2 Prenatal diagnosis of a hemoglobinopathy
is best done by DNA analysis of fetal cells obtained by sampling the chorionic villi.
Additional studies such as assays for total and conjugated bilirubin, urine urobilino-
gen, haptoglobin, and LDH are usually abnormal in cases of accelerated hemolysis,
regardless of cause. These determinations may be useful for following the severity and
progression of a hemolytic process, but they do not add more to establishing a specific
diagnosis.
On the basis of the positive sickle cell solubility test, hemoglobin electrophoresis was
performed to confirm the diagnosis (Fig. 57.2), because false-positive (paraproteins) or
false-negative (severe anemia, elevated haemoglobin F) results may be obtained with
the hemoglobin solubility screening test. Hemoglobin electrophoresis uses cellulose
acetate or agarose gels at pH 8.6 for convenient resolution of hemoglobins A, F, C, and
S. A second supplemental electrophoretic procedure is performed at acid pH (6.0) to
separate abnormal hemoglobins, such as hemoglobins D and G, which migrate with
hemoglobin S at pH 8.6.
In the electrophoretic procedure, the relative proportions of normal as well as abnor-
mal hemoglobins can be quantitated. In this case, the proportion of hemoglobin S (HbS)
was 82%, fetal hemoglobin (HbF) 14%, and hemoglobin A2 (HbA2) 4%. Many labora-
tories use high-performance liquid chromatography (HPLC) instruments for hemoglobin
analysis. The advantages of HPLC compared to electrophoresis include accurate quantifi-
cation of hemoglobins F and A2, and labor-saving automation (Fig. 57.3).
The patient had not received any erythrocyte transfusions in the previous several
weeks, and therefore there was no contamination of the specimen with normal adult hemo-
globin A (HbA) from transfused blood. A mistaken diagnosis of sickle cell trait could be
414 Case 57 A Child with Pneumonia

Figure 57.2 Cellulose acetate (pH 8.6, on left) and acid (pH 6.2 on right) electrophoresis gels; free
hemoglobin is applied in wells cut into gel (white arrows) and gel is placed in buffer oriented with positive
(þ) and negative (2) electrodes. At the conclusion of electrophoresis, hemoglobin is stained and scanned
in a densitometer to semiquantitate hemoglobin species. Top lane, contains patient’s hemoglobin (F,
14%; S, 84%; A2, not visible). Middle lane contains hemoglobins A and F from another patient. Bottom
lane contains control hemoglobins.

made in a patient with sickle cell disease who had recently been transfused with red cells
containing normal HbA. Whereas diagnostic electrophoresis should be restricted to a time
long after transfusion, effectiveness of a transfusion can be monitored by hemoglobin
electrophoresis. By measuring HbA and HbS periodically, the proportion of HbS can be
monitored and new transfusions invoked and thus avert complications of sickle cell
disease in selected patients at high risk for ischemic cerebral events, acute chest syndrome,
complications during pregnancy, or prior to elective major surgery.

Figure 57.3 HPLC analysis of patient with sickle cell disease. Following lysis of red cells, free
hemoglobin solution is applied to a cation exchange column. The column is perfused with a solution of increasing
cation concentration causing different hemoglobin species to elute at specific times. Hemoglobin A would elute
between peak F (HbF) and A2 (HbA2), but is absent on this graph because the patient was homozygous for
hemoglobin S.
 Treatment 415

Inherited conditions involving HbS in African Americans include sickle cell trait
(HbS plus normal HbA; prevalence 1 in 12), sickle cell disease (homozygous HbS; Preva-
lence in 1: 600) or combined with other hemoglobinopathies or thalassemias: SC hemo-
globinopathy (HbS plus HbC; prevalence 1 in 800), SD hemoglobinopathy (HbS plus
HbD, rare), and S-b-thalassemia (prevalence 1 in 600). Sickle cell trait is an asymptomatic
condition except under extreme hypoxic conditions. The other conditions are usually less
severe clinically than sickle cell disease (HbSS).

Pathophysiology

Substitution of valine for glutamic acid at amino acid position 6 of the b-globin chain
increases the affinity of deoxygenated hemoglobin S tetramers for each other, producing
spontaneous polymerization, and crescent-shaped red cells. The rigid sickle cells have
shortened lifespans and cause microvascular occlusions leading to ischemic injury in mul-
tiple tissues. A mild to moderate leukocytosis is common in sickle cell patients, and is
associated with increased morbidity and mortality, consistent with a role of inflammatory
mediators in vascular complications. The spleen and bone marrow are common sites of
vasoocclusive crises and tissue infarctions.

Treatment

Pain crises due to vasoocclusive events are the most frequent complaint of patients with
sickle cell disease. Bone pain, particularly in the legs and ribs, is the most common
symptom, as well as joint pain, headache, and abdominal pain. The standard approach
to management of pain crises is to evaluate and treat possible precipitating causes such
as infection, provide oral and intravenous hydration and supplemental oxygen, and to
relieve pain, typically with parenteral narcotics administered via a patient-controlled
analgesic pump. Red cell transfusions are not usually indicated for uncomplicated pain
crises. However, some patients with sickle cell disease do require intermittent transfusions
for severe anemia, complicated crises, prior to surgical procedures, or stroke prophylaxis.3
The many transfusions that these patients receive increase the risk of developing various
antibodies to donor erythrocytes. About one-quarter of sickle cell patients will develop anti-
bodies, and procuring compatible blood becomes more difficult. The use of designated,
related donors whose erythrocyte antigen phenotypes match those of the recipient lessens
the rate of immunization and also improves the chances of finding compatible blood.4
Another problem associated with chronic transfusions is transfusion hemosiderosis,
the buildup of stored iron in the patient’s body. Each unit of transfused erythrocytes con-
tains 150 – 250 mg of elemental iron. When the transfused cells finally are cleared, the iron
from their hemoglobin is stored in the reticuloendothelial cells. In addition, intestinal
absorption of dietary iron increases in patients with chronic hemolytic anemia. Both of
these mechanisms can cause massive storage of iron, which can lead to parenchymal
organ (liver, heart) and endocrine gland (especially pancreas) dysfunction.
Iron overload is a major concern for children at high risk for stroke based on transcra-
nial Doppler studies showing high blood flow rates in the middle cerebral or internal
carotid arteries. Chronic transfusions reduce strokes, but when stopped, the stroke risk
returns.5 The risk of iron overload may be lessened by use of partial red cell exchange
transfusions and iron chelation. Until recently, iron chelation therapy required daily pro-
longed subcutaneous infusion of deferoxamine. A long-awaited oral iron chelator,
416 Case 57 A Child with Pneumonia

deferasirox (Exjade), was approved by the FDA in 2005, and offers the potential for
reduction of iron overload complications in patients with chronic hemolytic anemia,
especially those with sickle cell disease and severe forms of thalassemia.6
The complications of vasoocclusive crises involve many organs including lung, liver,
brain (cerebrovascular accidents), penis (priapism), bone (aseptic necrosis), retina, kidney,
spleen, and skin (leg ulcers).7 Erythrocyte exchange transfusion can lead to healing of skin
ulcers such as this patient displayed, and primary and secondary prevention of strokes, as
well as reduction of morbidity from acute cerebral ischemia, priapism, and acute chest
syndrome. Congestive heart failure, chronic pulmonary hypertension, renal insufficiency,
and joint damage are common long-term complications. In children, the necrosis and
periosteitis of metacarpal and metatarsal bones causes a painful deformation termed
the “hand –foot syndrome.” Aplastic crisis (acute failure to produce erythrocytes)
may result from infection with human parvovirus B19 that selectively affects erythroid
precursors in bone marrow. A further complication of any hereditary hemolytic disorder
is formation of bilirubin gallstones to a degree that may require cholecystectomy.
Infection is the major cause of death in children with sickle cell disease because, after
loss of splenic function, susceptibility increases for infections with encapsulated organ-
isms, such as Streptococcus pneumoniae and Haemophilus influenzae. Osteomyelitis
with Salmonella is also common in patients with sickle cell disease. General preventive
measures include immunization with a polyvalent pneumococcal vaccine and chemo-
prophylaxis with antibiotics. Folate supplementation should also be administered to
prevent depletion in the presence of lifelong brisk hematopoiesis.
A number of innovative therapeutic initiatives are currently under active investi-
gation; they include trials of drugs that reduce hemoglobin S polymerization, bone
marrow transplantation, and gene therapy. Currently, the chemotherapeutic agent, hydro-
xyurea, which increases synthesis of HbF, is the only medication that can alter the clinical
severity of sickle cell disease.8 Increased concentration of intracellular HbF increases the
minimum gelling concentration of deoxygenated HbS solutions and reduces the likelihood
of sickling. Other affects of hydroxyurea that are associated with clinical improvement in
patients with sickle cell disease include reduction in neutrophil count and reduces red cell
adhesion to endothelial cells. Some medical centers are now performing bone marrow
transplant for hemoglobinopathies, primarily for treatment of thalassemia, but there
exists a potential for application to sickle cell disease for children at high risk of stroke.

References

1. STEINBERG , M. H.: The interactions of a-thalassemia
with hemoglobinopathies. Hematol. Oncol. Clin. North
Am. 5:453–73, 1991.
2. KAUFMAN , R. E.: Analysis of abnormal hemoglobins. In
Practical Laboratory Hematology, J. A. KOEPKE , ed.,
Churchill Livingstone, New York, 1991.
3. DANIELSON , C. F. M.: The role of red blood cell
exchange transfusion in the treatment and prevention of
complications of sickle cell disease. Ther. Apheresis
6:24–31, 2001.
4. KANTER , M. H. AND HODGE , S. E.: The probability
of obtaining compatible blood from related directedd
donors. Arch. Pathol. Lab. Med. 114:1013–16, 1990.
5. STOP2 Trial Investigators: Discontinuing prophylactic
transfusions used to prevent stroke in sickle cell
disease. N. Engl. J. Med. 353:2769–78, 2005.
6. CAPPELLINI , M. D.: Iron-chelating therapy with the new
oral agent ICL679 (Exjadew). Best Pract. & Res. Clin.
Haematol. 18:289–98, 2005.
7. CLASTER , S. AND VICHINSKY , E. P.: Managing sickle cell
disease. Br. Med. J. 327:1151– 55, 2003.
8. HALSEY , C. AND ROBERTS , I. A. G.: The role of hydroxy-
urea in sickle cell disease. Br. J. Haematol. 120:177–86,
2003.
 Additional Reading 417

Additional Reading

SAFKO , R.: Anemias of abnormal globin development- E. A. STIENE -MARTIN , C. A. LOTSPEICH -STEININGER ,
hemoglobinopathies. In Clinical Hematology— AND J. A. KOEPKE , eds., Lippincott, Philadelphia, 1992,
Principles, Procedures, Correlations, 2nd ed., pp. 192–216.