Clinicians in the ED should be aware of the common infectious foci and organisms, as severe infections in patients with thalassemia can exacerbate to sepsis and septic shock. Biliary tract infection, pneumonia, soft tissue infection, and liver abscesses are the most frequently reported sites of bacterial infections, and Klebsiella pneumoniae, Escherichia coli, Streptococcus pneumoniae, Salmonella typhi, Yersinia enterocolitica, and other Gram-negative bacteria are the main types of bacterial infections.
For patients with thalassemia who have a history of splenectomy, it is important to consider meningitis. Patients with non-TDT may develop sinusitis, which can increase the risk for meningitis and the formation of brain abscess. Evidence strongly suggests that delays of more than 1 hour in the administration of antibiotics can lead to a higher mortality rate in these patients.
The choice of antibiotic therapy should be guided by suspected source of infection, common hospital and community pathogens, age and comorbidities of the patient, and immunocompromising factors (HIV, neutropenia, splenectomy, etc.).
If a patient has fever or possible infection, clinicians should review patient history and physical examination findings, and monitor the patient for dyspnea or cough, abdominal pain or diarrhea, flank pain or lower urinary tract symptoms, and neurological symptoms. If there is an unclear focus, the authors of the review recommend echocardiography to check for endocarditis or dental panoramic radiography to check for dental abscess.
Clinicians should consider heart failure as an important differential even in younger patients with thalassemia. Although advances have been made in iron chelation therapy and therapy management of TDT, the leading cause of morbidity and mortality in this patient population is cardiovascular disease. In addition, cardiomyopathy is more common in patients with TDT compared with non-TDT.
Clinicians should check patient basic metabolic profile (renal function markers and electrolytes, including magnesium), liver enzyme and bilirubin levels, complete blood count, brain natriuretic peptide (BNP) levels, and obtain an electrocardiogram. It is also recommended that clinicians check troponin concentration. Thyroid function testing is recommended in cases of tachycardia or bradycardia.
Patients with thalassemia presenting to the ED with arrhythmias are managed in a similar fashion to those without thalassemia. Relevant tests include vital signs, electrocardiography, and a heart rate monitoring device.