Golden Tracheal Secretions and Bronchoalveolar Fluid During Acute Chest Syndrome in Sickle Cell Disease

Case Reports

Three young female patients with known homozygous sickle cell disease were admitted to our ICU over a 1-week period for acute respiratory failure due to ACS following painful vaso-occlusive crises. The baseline characteristics of sickle cell disease, clinical and laboratory features upon ICU admission, and outcomes of these 3 patients are reported in Table 1. All 3 developed severe acute respiratory syndrome, leading to tracheal intubation, prone positioning, and nitric oxide inhalation treatment. Intravenous antibiotic treatment, combining a third-generation cephalosporin and a macrolide, was administered to all 3 patients, but bacterial blood cultures and respiratory samples remained sterile. The condition improved in 2 patients, who were eventually discharged from the ICU 2 weeks later (patients 1 and 3), whereas one patient (patient 2) required venovenous extracorporeal membrane oxygenation and died on day 5.

In all 3 patients, tracheal secretions and bronchoalveolar lavage fluid (BALF) showed a yellowish plasma-like stain (Fig. 1, B–D; see the supplementary video at http://www.rcjournal.com). After normalization for the plasma-to-BAL urea ratio, BALF (vs plasma) protein (patient 1, 54 vs 57 g/L; patient 2, 45 vs 55 g/L) and lactate dehydrogenase (patient 1, 1,890 vs 1,529 U/L; patient 2, 795 vs 512 U/L) levels were similar and consistent with an exudative process. BALF bilirubin concentrations were 7 (patient 1) and 5 (patient 2) μmol/L, implying that the yellowish stain was not related to bilirubin content. Interestingly, tracheal secretions of patient 3 exhibited the same color as her plasma (Fig. 1C). Finally, in patients 1 and 2, 30% of alveolar macrophages were stained with Oil Red O (Fig. 1E), indicative of lung fat embolism.^3–5

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Figure 1.

Golden tracheal aspirates and bronchoalveolar lavage fluid (BALF) in patients with severe acute chest syndrome. A: Contrast-enhanced chest computed tomography scan depicting typical bilateral lung base consolidations in patient 1. B: Tracheal secretions from patient 1. C: Tracheal secretions (left tube) and plasma (right tube) from patient 3 showing the same yellowish color. D: Macroscopically golden BALF from patient 1. E: Cytological examination of BALF from patient 1 showing alveolar macrophages stained with Oil Red O.