The Clinical Problem Solvers Episode 102: Human Dx unknown with Arsalan & NYU residents – abdominal swelling & decreased appetite
Dr. Ryan Haran presents a Human Dx unknown to Arsalan and NYU residents – Drs. Jenny Whealdon and Greg Rubinfeld.
Dr. Jenny Whealdon
Jenny was born and raised on Bainbridge Island in Seattle, Washington. She attended Haverford College where she studied religion and theoretical chemistry; ultimately staying in the Philadelphia area to attend the University of Pennsylvania School of Medicine. There, she developed an interest in behavioral economics and decision making, particularly in the critical care setting. She completed her internal medicine training at NYU and is staying on as a Chief Resident.
Dr. Greg Rubinfeld
Greg is currently a chief resident at NYU Grossman School of Medicine.He aspires towards a career in academic cardiology where he hopes to find a marriage of his interests in thrombosis and coronary artery disease.When he is not in the hospital or at home with his wife and son, you might find him scuba diving wrecks along the east coast, nose deep in classic literature, or playing pick-up street hockey and collecting more bruises than he cares to admit.
Dr. Ryan Haran
Ryan grew up in Oregon and after attending Oregon State University went to medical school at Virginia Commonwealth University in Richmond, Virginia.He completed an internal medicine internship then spent a year as a radiology resident at Northwestern University in Chicago, Illinois before deciding that while radiology is cool and all he had learned too much medicine to just go and forget everything. As such, he decided to return to medicine and has now completed an internal medicine residency at his home institution of VCU where he will be staying on faculty as a hospitalist.
Case Recap
A 55-year-old previously healthy woman presented with subacute abdominal distension and acute emesis. On examination, she was found to be hypotensive and hypoxemic with evidence of ascites. Laboratory evaluation was notable for severe transaminase elevation (AST 2500, ALT 1300), leukocytosis to 53,000 per cubic millimeter, hemoglobin of 20 mg/dL, and a mildly elevated erythropoietin level. Imaging demonstrated an acute portal vein thrombus as well as a right-to-left intracardiac shunt. A bone marrow biopsy revealed trilineage hypercellularity with an erythroid predominance and JAK-2 positivity. The ultimate diagnosis was polycythemia vera with a secondary EPO-dependent polycythemia (likely secondary to her intracardiac shunt).
Teaching points
An absolute erythrocytosis refers to elevation in the red blood cell (RBC) mass and can be due to primary bone marrow, secondary (e.g., hypoxia, erythropoietin secreting tumors), and congenital etiologies. A key branch point is evaluation of the erythropoietin level (the primary stimulus for RBC synthesis), with normal/suppressed levels suggesting the presence of a primary or congenital disorder. Polycythemia vera (PV) is the most common primary erythrocytosis and lies on the spectrum of myeloproliferative neoplasms. Thrombosis and bleeding are life-threatening complications.