Pain is the leading cause of emergency department visits, hospitalizations, and daily suffering in individuals with sickle cell disease (SCD). The pathologic mechanisms leading to the perception of pain during acute RBC sickling episodes and development of chronic pain remain poorly understood and ineffectively treated. We provide the first study that explores nociceptor sensitization mechanisms that contribute to pain behavior in mice with severe SCD. Sickle mice exhibit robust behavioral hypersensitivity to mechanical, cold, and heat stimuli. Mechanical hypersensitivity is further exacerbated when hypoxia is used to induce acute sickling. Behavioral mechanical hypersensitivity is mediated in part by enhanced excitability to mechanical stimuli at both primary afferent peripheral terminal and sensory membrane levels. In the present study, inhibition of the capsaicin receptor transient receptor potential vanilloid 1 (TRPV1) with the selective antagonist A-425619 reversed the mechanical sensitization at both primary afferent terminals and isolated somata, and markedly attenuated mechanical behavioral hypersensitivity. In contrast, inhibition of TRPA1 with HC-030031 had no effect on mechanical sensitivity. These results suggest that the TRPV1 receptor contributes to primary afferent mechanical sensitization and a substantial portion of behavioral mechanical hypersensitivity in SCD mice. Therefore, TRPV1-targeted compounds that lack thermoregulatory side effects may provide relief from pain in patients with SCD. (Blood. 2011;118(12):3376-3383) IntroductionSickle cell disease (SCD) is a major health care and socioeconomic problem that affects millions of people worldwide. In the United States alone, SCD affects Ͼ 80 000 people, the majority of whom are African American. Pain is the hallmark symptom of SCD and the leading cause of emergency department visits, hospitalizations, and daily suffering. 1 Patients suffer unpredictable, incapacitating acute pain episodes that are believed to result from red blood cell (RBC) sickling and "vaso-occlusion." However, many features of this pain are not explained by hemoglobin polymerization and vascular obstruction. Furthermore, individuals with SCD often develop chronic pain syndromes that are poorly understood and ineffectively treated. 1,2 The frequency and severity of pain is associated with increased mortality and profoundly erodes patients' quality of life. 3 Because they are often from minority and lower socioeconomic groups, SCD patients are commonly underserved and suboptimally treated.The pathologic mechanisms leading to the perception of pain during RBC sickling episodes and the transition from acute to chronic pain remain poorly understood. 1,2 Patient descriptors of SCD pain include neuropathic pain attributes such as "aching," "shooting," and "stabbing," as well as nociceptive pain qualities such as "sharp," "throbbing," and "pounding." These descriptors depict spontaneous pain or nonstimulus-evoked pain. 2,4 Furthermore, increased hospital admissions and reports of...
DHTR/H syndrome occurs in pediatric SCD patients, typically 1 week posttransfusion, and presents with back, leg, or abdominal pain; fever; and hemoglobinuria that may mimic pain crisis. Hb is often lower than it was at the time of original transfusion, suggesting the hemolysis of the patient's own RBCs in addition to hemolysis of the transfused RBCs; a negative DAT and reticulocytopenia are often present. Severe complications including acute chest syndrome, congestive heart failure, pancreatitis, and acute renal failure were associated with DHTR/H syndrome in our patients. DHTR/H in the pediatric sickle cell population is a serious and potentially life-threatening complication of RBC transfusion. It is important to avoid additional transfusions in these patients, if possible, because these may exacerbate the hemolysis and worsen the degree of anemia. DHTR/H syndrome must be included in the differential of a patient who has SCD and vaso-occlusive crisis who has recently had a transfusion.
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