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Referral and warning signs
When to refer
Referral to specialized SCD clinic/Haematologist for: Diagnosis confirmation, Comprehensive care, Hydroxyurea/transfusion initiation, Severe/frequent VOC, Acute complications (ACS, stroke etc), Chronic organ damage.
Red flags
- Fever >38.5°C
- Signs of Acute Chest Syndrome
- Neurological symptoms (Stroke)
- Sudden severe pallor + enlarging spleen (Sequestration)
- Sudden severe pallor + low retics (Aplastic crisis)
- Priapism >2-4 hours
Signs and symptoms
- Chronic Haemolytic Anaemia: Pallor, fatigue, jaundice, gallstones.
- Vaso-occlusive Crises (VOC) / Painful Crises: Episodic acute pain (bone, chest, abdomen).
- Dactylitis ('Hand-Foot Syndrome'): Painful swelling hands/feet (infancy).
- Acute Chest Syndrome (ACS): Life-threatening. Fever, cough, chest pain, dyspnoea, hypoxia, CXR infiltrate.
- Stroke: Ischaemic or haemorrhagic. Higher risk in children.
- Splenic Sequestration Crisis: Rapid spleen enlargement, severe anaemia, shock (young children).
- Aplastic Crisis: Temporary RBC production halt (Parvovirus B19), rapid Hb drop, low retics.
- Increased infections: Due to functional asplenia (risk of encapsulated organisms).
- Chronic Organ Damage: Leg ulcers, Avascular necrosis, Retinopathy, Pulmonary hypertension, CKD, Cardiomyopathy, Priapism.
Risk factors
- Inherited genetic disorder (autosomal recessive).
- Homozygous HbS (HbSS) or compound heterozygous (HbSC, HbS/beta-thal).
- African, Mediterranean, Middle Eastern, Indian ancestry.
Diagnosis
Clinical assessment
Suspect based on symptoms (recurrent pain, anaemia, jaundice, dactylitis) and ethnic background/family history.
Investigations
- Haemoglobin Electrophoresis / HPLC: Confirmatory test. Identifies Hb types (HbS, HbA, HbF etc) and determines genotype (SS, SC, AS etc).
- CBC & Peripheral Blood Film: Chronic anaemia, high retics, sickle cells, Howell-Jolly bodies.
- Sickling Test: Screening only, confirms HbS presence.
- Transcranial Doppler (TCD) Ultrasound: Screen children for stroke risk.
- Baseline organ function tests (renal, liver, echo, eye exam).
Diagnostic criteria
Demonstration of predominantly HbS on haemoglobin electrophoresis/HPLC.
Management
Non-pharmacological management
- Comprehensive Care (Specialized clinic): Education, Hydration, Avoid triggers (cold, dehydration, stress), Folic Acid 5mg daily, Prompt infection management, Psychosocial support.
Pharmacological treatment
- Pain Management (VOC): Mild/Moderate (Home - hydration, warmth, Paracetamol, NSAIDs, weak opioids). Severe (Hospital - IV hydration, Oxygen if hypoxic, Strong opioids - Morphine, NSAIDs).
- Malaria Prophylaxis: Lifelong recommended in endemic areas.
- Penicillin Prophylaxis: Oral Pen V BID from infancy to age 5+.
- Vaccinations: Crucial. Routine + Pneumococcal (PCV, PPSV23), Meningococcal, Influenza.
- Hydroxyurea (Hydroxycarbamide): Increases HbF, reduces VOC/ACS. Indicated for frequent VOC, severe anaemia, history ACS/stroke. Specialist initiation/monitoring.
- Blood Transfusion: Simple (severe acute anaemia, ACS, stroke, pre-op). Exchange (acute stroke, severe ACS). Chronic (stroke prevention).
- Iron Chelation: If chronic transfusion iron overload.
- Manage Specific Complications (ACEi for nephropathy etc).
Monitoring
Regular follow-up. Monitor growth, CBC, retics. Annual organ function screen (renal, liver, echo, eye). Annual TCD (children). Monitor HbF/CBC on Hydroxyurea.
Complications
- VOC, ACS, Stroke, Avascular Necrosis, Chronic Organ Damage (kidney, lung, heart, eye), Leg Ulcers, Gallstones, Priapism, Infections, Splenic Sequestration/Infarction, Aplastic Crisis.
Prevention
- Genetic counseling, prenatal diagnosis.
- Newborn screening.
- Prophylactic penicillin and vaccinations.
- Malaria prophylaxis.
- Hydroxyurea.
- Stroke prevention (TCD + transfusion).
Patient education
- Understanding SCD.
- Recognizing triggers.
- Importance of hydration.
- Pain management plan.
- Recognizing serious complications.
- Importance of prophylaxis (folic acid, penicillin, malaria) & vaccinations.
- Hydroxyurea therapy details if applicable.
- Genetic counseling.
Uganda-specific notes
High prevalence. Newborn screening not widespread. Malaria/pneumococcal prophylaxis critical. Access to Hydroxyurea, TCD, transfusion (esp exchange) limited. Osteomyelitis often Salmonella.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 11, Section 11.1.3
- National Sickle Cell Disease Guidelines, MOH Uganda
(Refer to specific MOH guidelines)