A 22-year-old male with sickle cell disease (SCD) presented to the emergency department with a chief complaint of acute left lower extremity pain and a non-productive cough. PA and lateral chest roentograms were obtained revealing biconcave vertebral defects or "fish mouth" vertebrae. Developing in greater than seventy percent of patients with SCD, the depicted vertebral changes result from infarction of the vertebral bodies and thinned trabeculae allowing hyperplastic marrow to expand into the central vertebral space (solid arrows, Panels A and B). Debate exists regarding appropriate terminology as "fish" or "fish mouth" vertebrae. Though the appearance of the intervertebral disks resembles a fish mouth, the biconcave vertebral bodies are strikingly similar to a salmon?s vertebrae (dashed arrow, Panel C*). Since the majority of sickle patients will develop biconcave vertebrae independent of fractures, indicative of bone softening and infarction, this is an important clinical issue for clinicians of which to be aware.

* Image courtesy of Jason Rexroad and Jeffrey Georgia, National Navy Medical Center, Bethesda, MD.