A Case of Splenic Infarction at High altitude in Sickle Cell Trait
About the author – Dr Alison Cook is a G.P. with a keen interest in expeditions and the medical issues in remote locations. She has attended the Expedition and Wilderness Medicine course in Keswick and has worked as an expedition medic for Across the Divide Expeditions in locations diverse as Namibia and Peru. Alison has also worked with Medecins Sans Frontieres (MSF) in Niger.
In March 2007 an ATD client with undiagnosed sickle cell trait (SCT) suffered a splenic infarction on a high altitude expedition. Although the phenomenon of splenic infarction in SCT at high altitude is well documented, it is a relatively rare event and therefore a worthwhile case to share amongst expedition medics.
I was the doctor for one of Across the Divide’s Peru treks when this unfortunate chain of events occurred. A couple of hours after landing in Cusco (3300M altitude), a client developed acute abdominal pain. He was a physically fit, 23 year old white man, with an unremarkable medical history. His initial symptom was mild-moderate epigastric pain and abdominal examination revealed a soft abdomen, tender in the epigastric region. Half an hour later he developed vomiting and over the course of the next couple of hours the upper abdominal pain became progressively worse. Thankfully we had only journeyed about an hour from Cusco so an easy transfer via taxi back to a hospital in Cusco was quickly organised.
On arrival in the clinic the patient was managed with oxygen, I.V. fluids and opioid analgesia. He was referred for a surgical opinion and the diagnosis of splenic infarction was subsequently made. Examination at this time revealed generalised tenderness, worst in the upper abdomen with marked pain on percussion over the spleen. An ultrasound scan revealed splenic enlargement and total splenectomy was performed within a few hours.
On return to the UK the client was referred to a haematologist and the diagnosis of SCT was made. The client had some Greek ancestry – his maternal grandfather being Greek. The large majority of people with SCT do not suffer health problems as a result of their condition, consequently many people are unaware of their diagnosis. Splenic infarction occurs at altitude in SCT because the red blood cells are subjected to low oxygen tensions which causes them to sickle and become lodged in the vasculature of the spleen.
There are 47 cases of splenic infarction at altitude recorded in the literature. Many of the cases have been successfully managed conservatively and others have undergone splenectomy. Conservative management with fluids, oxygen, analgesia and descent if possible, is considered appropriate first line therapy. Use of the hyperbaric chamber, although not documented, may also help. Surgical intervention may be necessary if conservative management fails or complications arise (eg. splenic rupture, abscess/pseudocyst formation or sepsis).
Since this case Across The Divide have made some changes to their pre-departure medical questionnaire – clients are now asked if they have a personal/family history of sickle cell or any other blood disorder or if they come from an area where sickle cell is common. If they answer positively to any of these questions they are advised to see their doctor to have a medical check – hopefully this way people with SCT can be diagnosed and counselled prior to departure. This does however rely on the GP having an awareness of this rare complication of altitude, so it’s something for expedition medics to look out for on pre-departure medical forms. We now have an ethnically very diverse population in the UK and people do not always know their sickle cell status – if there are doubts they can be offered a screening test prior to departure.
So… this case is one for the memory bank of expedition medics on trips to high altitude!