Background : Sickle cell disease (SCD) is the most common hemoglobin anomaly in the United States and has numerous complications. Intravenous (IV ) fluid hydration is a principal element in the management of pain crisis. Intravenous hydration is commonly used in the treatment of vasoocclusive crises , as dehydration promotes erythrocyte sickling. Potential complications of continuous fluid replenishment include weight gain, heart failure, pulmonary edema and lower extremity edema.

Case Presentation : This is a case of a 25-year-old female with a past history of SCD who was admitted for an acute pain crisis. Her symptoms of generalized myopathy was precipitated after drinking 2 bottles of beer. On presentation, her vitals were T 97.5 F ,BP 104/75, HR 124, RR 27, SpO2 100% on room air. Blood alcohol level was 180, reticulocyte count 15.6, urine screen was positive for alcohol and THC, hemoglobin and hematocrit were 8.9 & 25.6. She received a bolus of normal saline (NS) and was started on D5W 0.3%NS. Her pain was controlled with a multimodal approach using NSAIDS, heat patches, Duloxetine and a Hydromorphone PCA pump. Due to poor oral intake, she continued to be on maintenance IV fluids. On day 7 of admission, the patient reported chest pain with BP 88/53,HR 109, RR 28, sPO2 88%at room air. Chest x-ray revealed bilateral perihilar and basilar alveolar opacities with obscured hemidiaphragms, costophrenic sulci and portions of heart borders, which were new findings. Troponins drawn eight hours apart read 345> 408>160 respectively. The patient was started on Levofloxacin due to allergies to other antibiotics. An exchange transfusion improved her symptoms.

Discussion : Alcohol is a diuretic that can worsen volume status and cause dehydration thereby promoting sickle cell clumping and triggering a crisis. ACS is a form of acute lung injury defined by new pulmonary findings on chest x-ray combined with ≥ 1 manifestation such as cough, fever, chest pain, tachypnea, dyspnea, sputum production, or new-onset hypoxia. The vital signs and new radiologic findings due to volume overload IV fluids were consistent with ACS. Prolonged periods and insufficient monitoring of hydration status could lead to complications of hyperhydration that could present as an ACS. There are currently no guidelines for fluid replacement in patients with SCD. Taking this into account , the provider should guide clinical decision on choice and duration hydration. Improving the awareness of this potential effect among health care providers would also prevent complications.