Hemoglobin electrophoresis: An important investigation in the evaluation of patients with massive hematuria

II Ulasi, CK Ijoma 
 Renal Unit, Department of Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria

Correspondence Address:
I I Ulasi
Renal Unit, Department of Medicine, University of Nigeria Teaching Hospital, Enugu
Nigeria

Full Text

Sir,

We report a case of a 34-year-old Nigerian woman who presented at the renal clinic of a University Hospital in Nigeria in July 2003 with a history of sudden onset of painless, profuse and persistent hematuria. She had fever and rigors at the onset of illness which were relieved by antipyretics. There were no other urinary symptoms; neither did she have sore throat, skin rash, abdominal pains nor bone pains. She denied use of any herbal mixtures or abuse of analgesics. She was engaged in subsistent farming and lived in the village.

Physical examination revealed no abnormality except moderate anemia. The significant findings from laboratory investigations were: mild proteinuria, severe hematuria. Schistosoma ova were not seen in urine microscopy. Abdominal ultrasonography revealed no abnormality but the intravenous urography (IVU) was remarkable with features suggestive of pyelitis. There was blunting of the calyces with filling defects (blood clots) in both pelvises. Also noted were kinking of the right ureter [Figure 1] and ureterocele in the left ureter [Figure 2]. There was no renal cyst or evidence of neoplasm. Urine culture yielded no growth after 48h (she had previously been treated with antibiotics prior to presentation) and the fasting blood sugar was normal (5.6mmol/l). Hemoglobin electrophoresis revealed sickle cell trait (HbAS) with percentages of Hb A and Hb S 60% and 40%, respectively, and hemoglobin was 8.5g/dl. There were no bleeding or clotting abnormalities. The platelet count was above 250,000/cumm. She was given a 10-day course of ofloxacin tablets, hematinics and advised to take lots of fluids. Symptoms resolved within five days of commencing therapy and repeat urine examination after two weeks showed no abnormality.

Though sickle cell trait is asymptomatic, it can be responsible for renal abnormalities such as gross hematuria. [1] Factors that predispose a sickle cell trait patient to hematuria include- urinary tract infection (UTI), trauma, instrumentation and analgesic consumption. Other causes of hematuria in sickle cell disease include renal medullary carcinoma [2] and use of toxic/herbal agents.

The bleeding can be massive with clots as was the case with our patient. Duvic et al. , [1] also documented clots in some patients with sickle cell trait that they studied. The prevalence of hematuria in sickle cell disease varies from nil to 30% in some series. [3],[4] Remarkably, there was involvement of both kidneys in our patient. This occurs in only about 10% of cases. [5]

This patient's hematuria may have been precipitated by UTI despite negative urine culture. The negative culture result could be attributed to the antibiotics she had received prior to presentation. In addition, the resolution of hematuria within five days of commencing antibiotic therapy and the evidence of pyelitis in the IVU suggest the presence of upper UTI as the precipitating factor.

The incidence of sickle cell trait in the African black population is between 20% and 40%. In Nigeria, it is currently estimated that about 25% of adults have sickle cell trait. The epidemiological implication is obvious. This case underscores the need for sickling test and hemoglobin electrophoresis in the evaluation of every patient with unexplained hematuria, especially black patients.

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