Instructive Case - cont'd

I've always wished that I could produce from memory something pithy and perfect and exactly appropriate from Milton, or Shakespeare, or maybe Pope or Shaw, but I can't. However one thing that I can't seem to get rid of is:  This Case, like first love...very instructive, which is from a Charlei Chan movie. Of course almost no one except for some older cruciverbalists remembers Charle Chan or his three movie portrayers and first love tends to hit at an age when instruction and education are impossible. Now that I've used it up, I hope it will vanish from my memory forever.

The question I asked the patient was - Have any relatives who are anemic?  The answer was, "Why yes, my grand mother had sickle cell disease." No one ever asked me that before."

Now let's get into the case itself. There was early intrauterine pregnancy without any unusual pelvic findings. The two pictures are, obviously, the gall bladder (conventional 2D and  a 3D surface reconstruction, in which the anterior part of the gall bladder has been escised revealing the mucosal floor and stone floating just above it.It has been our practice since we started using phased array imaging in 1976 to do a survey of everything visible transabdominally in everyone referred for any type of abdominal or pelvic ultrasound. In the second or third trimesters of pregnancy, we tend to focus on the fetus, but we will a more extensive maternal exam with even the most minimnal of reasons. We don't charge anything extra for our surveys, they only add a minute or two to the exam, they provide a cache of valuable clinical information, establish a baseline should a question come up in the future, and during the process, patient's often volunteer a lot of relevant history, since they perceive that this is a real medical exam.

Gallstones are highly prevalent, making this one of the commonest intended or unexpected ultrasound imaging findings.In this case we have a young (slender) woman (not a lot of subcutaneous fat to be seen) with a single, larger stone that floats in bile at the distal end of the gall bladder (not the dependent neck region with the patient supine). There is no acoustic shadowing, gall bladder volume is normal, and the wall is thin and delicate.

Typical cholesterol stones are typically preceeded by progressine chronic focal cholecystitis with puntate scarring showing up as reflective patches in the submucosa and as distinct ridging, usually transverse to the axis of the gallbladder) in 3D cutaway views of anterior or posterior lumenal surfaces. The posterior surface, here is absolutely smooth and pristine. All of which suggests that this stone is most likely due to chronic intermittent episodes of hemolysis.  An additional finding was a splenic accessory, next to a slightly rounded tip of a normal sized spleen with a uniform sonic architecture.

The 'incidental' finding now makes us think of Sickle trait or one of the sickle trait variants.Aside from the frequency of renal papillary necrosis and wel described renal concentrating issues in older patients with sickle trait, there is always the worry that episodes of sickling can occur whenever and wherever there may be hypoxia. The prototype and tragic example is sudden death during exercise in black military recruits, which received a lot of attention in the 1980's leading to recognition of this problem and steps for its prevention. Dancers, like this patient, often have workouts that put to shame what a lot of professional athletes can indure. 

There is a really great article about sickle trait by Dr John Kark of the Howard University School of Medicine that you may find really instructive by clicking here.