A 34-year-old African American woman with sickle cell disease and history of relatively severe hemolysis, chronic leg ulcers, and mild pulmonary hypertension presented with a new ischemic stroke. Recent research has suggested a syndrome of hemolysis-associated vasculopathy in patients with sickle cell disease, which features severe hemolytic anemia and leads to scavenging of nitric oxide and its biochemical precursor L-arginine. This diminished bioavailability of nitric oxide promotes a hemolysis-vascular dysfunction syndrome, which includes pulmonary hypertension, cutaneous leg ulceration, priapism, and ischemic stroke. Additional correlates of this vasculopathy include activation of endothelial cell adhesion molecules, platelets, and the vascular protectant hemeoxygenase-1. Some known risk factors for atherosclerosis are also associated with sickle cell vasculopathy, including low levels of apolipoprotein AI and high levels of asymmetric dimethylarginine, an endogenous inhibitor of nitric oxide synthase. Identification of dysregulated vascular biology pathways in sickle vasculopathy has provided a focus for new clinical trials for therapeutic intervention, including inhaled nitric oxide, sodium nitrite, L-arginine, Corresponding Author: Gregory J. Kato, MD, Critical Care Medicine Department, Clinical Center, National Institutes of Health, 10 Center Dr, MSC 1476, Bldg 10-CRC, Room 5-5140, Bethesda, MD 20892-1476 Financial Disclosures: Dr Gladwin reports being named as a coinventor on a National Institutes of Health (NIH) government patent application for the therapeutic use of nitrite salts for cardiovascular indications and on a second patent for a hemoglobin-based blood substitute. Dr Kato reported no disclosures.
Additional Information:The patient data were collected as part of a registered clinical research protocol (clinicaltrials.gov identifier NCT00081523). The patient presented in this article reviewed its contents and consented in writing to its publication.
CASE PRESENTATIONThe patient is a 34-year-old African American woman with homozygous sickle cell disease (SCD) undergoing hydroxyurea therapy for several years, with an 18-year history of leg ulceration (Figure 1). Steady-state laboratory values included hemoglobin 8.7 g/dL (35th percentile for SCD patients evaluated at the National Institutes of Health [NIH] between 1999[NIH] between -2003, reticulocyte count 370×10 3 /μL (83rd percentile), and serum lactate dehydrogenase (LDH) highly elevated at 486 U/L (83rd percentile). The ratio of plasma arginine to ornithine was 0.54 (33rd percentile). The patient was found to have mild elevation of the N-terminal pro-brain natriuretic peptide (NT-proBNP) level at 177 pg/mL, and on Doppler echocardiography, a borderline high tricuspid regurgitant jet velocity of 2.5 m/s, both suggestive of mildly elevated pulmonary systolic pressures.During a subsequent hospitalization for vaso-occlusive crisis, the patient developed clinical features of encephalopathy, renal insufficiency, and pulmonary infiltrat...