University of Oradea, Romania
Title: Diagnosis traps in a rare hematologic disease, Original case report
Manuela Stoicescu was Assistant Researcher at University of Cluj Napoca and now she is consultant internal medicine physician, Ph.D., Assistant Professor of University of Oradea, Faculty of Medicine and Pharmacy, Medical Disciplines Department, Romania. Also work at Emergency Hospital Internal Medicine Department and Internal Medicine Office. She has published two books, one monograph and papers in reputed journals. She was invited as a speaker at 9 national and 15 International conferences. She is Member of Romanian Society of Internal Medicine, Cardiology, Medical Chemistry, Biochemistry and Member of the Balkan Society of Medicine.
Objectives: The main objective of this study of case was to discover the real cause of a patient who was hospitalized for an episode of right deep vein thrombosis. Methods: Present clinical case of a man aged 65 years, consuming alcohol, non smoker, which working as a car dyer 15 years and he was hospitalized for an episode of deep vein thrombosis. It also presence high blood pressure with medium value (160/100mmHg) under treatment with ACE inhibitor – Enalapril 10mg/day by six years. During this time he presented two episodes of transient ischemic stroke attack which were interpreted at the time as background hypertensive and also presented an acute attack of gout resolved spontaneously. The patient noted indifference to these premonitory symptoms, ignored his symptoms and he didn't present to the doctor he presentled only when appeared the right deep vein thrombosis. At objective examination attracst attention is the very red face, Homan’s sign and Lisker sing were positive, the inferior pole of spleen was palpable, BP=160/90mmHg, heart rate=82beats/min, vesicular sound were normal and except these changes the physical examination was normal. The deep venous Eco Doppler was performed and confirmed the presence of blood clot in the right popliteal vein and abdominal echo confirm splenomegaly.The laboratory tests were:VSH=90/110mmHg,fibrinogen=523mg%, Hb=20g/dl, Ht=62%, Hematii=12.000.000/mmᶟ, eritrocitar volume measured by marked red blood cell with Cr 51= 40ml/kg(increased), leukocyte=8 000 /mmᶟ , platelets=150 000 /mmᶟ , lymphocyte=2%, neutrophils=4%, eosinophils= 3%, reticulocyte=1%˚, HEM, CHEM, VEM, RDW were in normal ranges, acid uric=9,8 mg/dl, peripheral blood smear- numerous red cells were seen, neutrophil alkaline phosphatase was increased, serum erythropoietin was decreased, normal Astrup excluded hypoxia and as secondary poliglobulia in this context, the setting of a normal Pao2 is diagnostic, sternal puncture- marrow shows hypercellularity with erythroid hyperplasia confirmed safe the diagnosis of primary erythrocytosis. Results: At the first view this clinical case appeared to be a usually (simple) case of deep vein thrombosis. The two episodes of transient ischemic stroke attack could be interpreted initially in the context of hypertension and acute attack of gout, hyperuricemia and red faces in context of alcohol consumption. What initially drew attention to an alternative diagnosis were very high inflammatory syndrome and excessively high hemoglobin value, hematocrit and red blood cell number. Subsequently other specific investigations have confirmed the actual diagnosis. Conclusions: 1. Episode of right deep vein thrombosis was actually in the context of hyper viscosity syndrome and in neoplasic context. 2. Two episodes of transient ischemic stroke attack were also in the context of hyper viscosity in the myeloid proliferative syndrome. 3. Acute attack of gout resolved spontaneously was actually on background of the secondary hyperuricemia in the myeloid proliferative syndrome and secondary gout in this context explained by increased cell turn-over. 4.Patient face - very red- could draw attention to diagnosis but also may be confused with alcoholic faces. 5.Peripheral blood aspect showed only proliferation of the erythrocyte series except for other series. 6. Astrup normally result excluded hypoxia and such secondary poliglobulia. 7. Sternal puncture confirmed safe the real diagnosis- primary erythrocytosis because marrow shows hypercellularity with erythroid hyperplasia. 8. Finally the question is if the risk factors of the workplace of the patient- he was car dyer - could be considered in causing of this very rare hematological disease- primary erythrocytosis or Policitemia Vera.