Flash Pulmonary Edema After Unnecessary Normal Saline Infusion Unmasking Sickle Nephropathy: Highlighting the Controversy of Routine Fluid Use in Vaso-Occlusive Crisis.

Abstract

Acute pulmonary edema following routine fluid administration is an uncommon but potentially life-threatening complication in adults with sickle cell disease (SCD). We report the case of a 42-year-old male with known SCD who presented with severe generalized body pain consistent with vaso-occlusive crisis (VOC). Initial management included intravenous normal saline for mild dehydration. Shortly after receiving approximately 500 mL, he developed acute shortness of breath, hypoxia, and fine basal crackles. Chest imaging demonstrated bilateral alveolar infiltrates consistent with pulmonary edema. Laboratory evaluation revealed baseline anemia, mild leukocytosis, elevated creatinine, and trace proteinuria, suggestive of subclinical sickle nephropathy. Echocardiography showed normal cardiac function, excluding primary cardiogenic causes. The patient received supplemental oxygen, cautious diuretics, and pain control while fluid administration was restricted. Transfusion support was provided to improve oxygen-carrying capacity and reduce sickling risk. Multidisciplinary management included hematology, nephrology, and respiratory care teams. The patient’s respiratory status gradually improved, and pulmonary edema resolved without further complications. This case highlights the risk of flash pulmonary edema triggered by standard intravenous fluids in patients with SCD and previously undiagnosed renal impairment. It underscores the importance of individualized fluid management, careful monitoring, and early recognition of subclinical sickle nephropathy. Clinicians should exercise caution with routine fluid boluses in VOC, even in patients without overt kidney disease, as modest fluid volumes may precipitate life-threatening pulmonary complications. Prompt identification and tailored therapy can prevent morbidity and guide safe management of VOC in adults with SCD.