A 67-Year-Old Man with Polycythemia Vera
Prithviraj Bose, MD introduces a polycythemia vera (PV) patient case featuring a 67-year-old man presenting with frequent headaches and dizziness.
Prithviraj Bose: Hi, I'm Prithviraj Bose. I'm an associate professor in the Department of Leukemia at MD Anderson Cancer Center in Houston, Texas.
So we're going to get started with the case. And here we have a 67-year-old man presenting with frequent headaches and dizziness. He's been a smoker, at least in the past, and his exam is OK. It's unremarkable, no splenomegaly, but the labs show a super high hemoglobin at 20.5 with a hematocrit of 60%. The white cells are a little elevated at 13. Platelets are 380, so normal. And the MCV is 72. The patient is found to have a JAK2V617F mutation. The allele burden is on the high side at 65%. The bone marrow shows trilineage proliferation and pleomorphic mix. And the patient is started on phlebotomy and aspirin. Now, three months later, this is now May 2018, the patient has undergone three phlebotomies in the preceding three months. He continues to complain of dizziness, headaches, and nausea. And since he's been on phlebotomy still, and of course aspirin, hydroxyurea is started at 1000 milligrams per day. Note that this patient is also 67. Three months later, this is now August, 2018, he has continued to need phlebotomies despite the Hydrea. He's actually had five phlebotomies since his last visit. And so at this point, the physician increases his hydroxyurea to 1500 milligrams a day. Another three months pass, and now the patient is still requiring phlebotomies and complaining of itching, pruritus. And at this point, the dose of hydroxyurea is increased to 2000 milligrams per day. Three months later, he returns for follow-up. This is now February 2019, a year since he first presented. And now with the higher dose of Hydrea, he has had slightly fewer phlebotomies, but still two since the last visit. He's also experiencing abdominal fullness and dysgeusia, perhaps from that high dose of Hydrea. And his spleen is now palpable six centimeter below the left costal margin.
