1. THE PARADOXICAL RBC MEDICINE GRANDROUNDS December 2, 2010 Presented by: Suzanne V. Santos, M.D. Moderator: Jesus A. Relos, M.D., FPCP

2. Objectives Objectives 1. To discuss the diagnostic approach in a patient presenting with erythrocytosis and thrombocytosis. 2. To present an unusual case of Beta Thalassemia intermedia with possible concurrent polycythemia vera. 3. To discuss the pathophysiology, diagnosis and treatment of polycythemia vera and beta thalassemia and their risk for thrombotic events.

3. General Data A.B. 56 year old male Seaman

4. Chief Complaint Headache

5. History of Present Illness 14 years PTC elevated BP 150-160/80 (1995) occasional headache Consultation done: Dx. Hypertension stage II 10 years PTC Dx: Dyslipidemia (2005)Hyperuricemia

6. History of Present Illness 3 months PTC occipital headache, (Oct. 2009) throbbing, grade 5-6/10 consultation: CBC: elevated Hgb (19.3), Hct (60) Blood volume studies Referral to hematologist

7. Review of Systems No fever No weight loss No loss of appetite No dizziness No nausea/vomiting No easy bruisability No bleeding tendencies No mouth sores No skin rashes No hair loss

8. Past Medical History Hypertensive for 14 years Usual BP 120-130/80, Highest BP 160/90 Maintenance: Losartan 100mg/tab, 1 tab OD Amlodipine 10mg/tab, 1 tab OD Imidapril 10mg/tab, 1 tab OD Chronic Kidney Disease x 1 year, Rx: Sodium Bicarbonate 650mg/tab, 1 tab BID Dyslipidemia for 10 years Simvastatin 80mg/tab, 1 tab ODHS Hyperuricemia for 10 yrs, on Allopurinol 300mg/tab 1 tab OD

9. Non-smoker Occasional Alcoholic Beverage Drinker No history of Illicit Drug Use Personal/Social History

10. Unremarkable Family History

11. Physical Examination BP: 130/90, CR: 74 bpm regular, R: 20 cpm,T: 36.8  C Ht: 167.64 cm, Wt: 68 kg, BMI: 24 kg/m 2 General appearance: conscious, coherent, not in cardiorespiratory distress, ambulatory, oriented to 3 spheres Skin: flushed, moist skin, no rashes over face or body HEENT: plethoric, pink palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no cervical lymphadenopathy, no palpable neck mass, thyroid not enlarged

12. Physical Examination CHEST and LUNGS: symmetrical chest expansion, no retractions, clear breath sounds, no crackles or rhonchi, no wheeze HEART: quiet precordium, apex beat at 5 th ICS left mid clavicular line, regular rate and rhythm, no murmurs. No S3, No S4 gallop, S1>S2 apex, S2>S1 base, JVP at 9 cm, distinct heart sounds ABDOMEN: Flabby abdomen, soft, nontender, normoactive bowel sounds, no hepatosplenomegaly EXTREMITIES: no cyanosis, no edema, full and equal pulses, no nail changes, no tender or swollen joints Neurological Examination: essentially normal

13. Salient Features 56 year old male Headache Elevated blood volume studies 14 yrs history of elevated BP 10 yrs history of hyperuricemia Non smoker Plethoric Hgb 19.3, Hct 60

14. Initial Clinical Impression Myeloproliferative Disorder probably Polycythemia Vera Hypertensive Cardiovascular Disease Dyslipidemia Hyperuricemia Chronic Kidney Disease probably secondary to Hypertensive Nephrosclerosis

15. Definition of Terms Hemoglobin (Hgb): concentration of the major oxygen-carrying pigment in whole blood; tetramer consisting of a pair of α -like chains and β -like chains Hematocrit (HCT): percentage of a sample of whole blood occupied by intact red blood cells. RBC count: number of red blood cells contained in a specified volume of whole blood. Erythrocytosis: increased red cell mass Polycythemia: hemoglobin, red blood cell (RBC) count, and total RBC volume are all above normal.

16. Definition of Terms Hemoglobin (Hgb): concentration of the major oxygen-carrying pigment in whole blood; tetramer consisting of a pair of α -like chains and β -like chains Hematocrit (HCT): percent of a sample of whole blood occupied by intact red blood cells. RBC count: number of red blood cells contained in a specified volume of whole blood. Erythrocytosis: increased red cell mass Polycythemia: any increase in red cells Men: Hgb > 17 g/dL; Hct > 50% Women: Hgb > 15 g/dL; Hct > 45% Men: Hgb > 17 g/dL; Hct > 50% Women: Hgb > 15 g/dL; Hct > 45%

17. Definition of Terms Microcytosis: MCV < 80 Macrocytosis MCV >100 Hypochromia: low values of MCH and MCHC MCV: volume of the average circulating RBC MCH: hemoglobin content of the average circulating RBC MCHC: hemoglobin concentration within circulating RBC

18. Problem: Erythrocytosis & Thrombocytosis DATE2/3/092/10/092/19/09 Hgb19.3 H17.60 H14.5 Hct60 H55.90 H46.8 RBC7.927.47 H6.27 WBC9.8610.549.55 Segs7665 lymph202530 eos11 monos892 Plt334K459K H427K MCV74.8 L74.6 L MCH23.6 L23.1 L MCH C 31.5 L31 L RDW17.3 H15.8 H Phlebotomy: 1 st consult (2/3/09) 3 rd consult (2/5/09) 10 th consult (2/12/09)

19. Complete Blood Count 2/11/10

20. Problem: Erythrocytosis & Thrombocytosis Cranial CT scan without contrast: (Feb. 16, 2010) Suspicious small infarct, anterior limb of the right internal capsule. Microvascular disease. Atherosclerotic disease of the vertebro-basilar and internal carotid arteries.

21. Problem: Erythrocytosis & Thrombocytosis WHO Classification of Chronic Myeloproliferative Disorders (Neoplasm) Chronic Myelogenous Leukemia Chronic Idiopathic Myelofibrosis Essential Thrombocytosis Polycythemia Vera

22. Problem: Erythrocytosis & Thrombocytosis WHO Classification of Chronic Myeloproliferative Disorders Chronic Myelogenous Leukemia Chronic Idiopathic Myelofibrosis Polycythemia Vera Chronic Myelogenous Leukemia translocation between chromosome 9 and 22 resulting in fusion of the BCR gene on chromosome 22q11 with the ABL gene on chromosome 9q34 elevated WBC, plt count low LAP score Chronic Myelogenous Leukemia translocation between chromosome 9 and 22 resulting in fusion of the BCR gene on chromosome 22q11 with the ABL gene on chromosome 9q34 elevated WBC, plt count low LAP score Patient Detection of BCR-ABL Gene Fusion by FISH (4/12/10): 1% found positive normal WBC high LAP score at 189 Patient Detection of BCR-ABL Gene Fusion by FISH (4/12/10): 1% found positive normal WBC high LAP score at 189

23. Problem: Erythrocytosis & Thrombocytosis WHO Classification of Chronic Myeloproliferative Disorders Chronic Myelogenous Leukemia Chronic Idiopathic Myelofibrosis Polycythemia Vera Chronic Idiopathic Myelofibrosis marrow fibrosis, extramedullary hematopoiesis, splenomegaly Blood smear: teardrop-shaped red cells, nucleated red cells, myelocytes, promyelocytes Chronic Idiopathic Myelofibrosis marrow fibrosis, extramedullary hematopoiesis, splenomegaly Blood smear: teardrop-shaped red cells, nucleated red cells, myelocytes, promyelocytes Patient Bone Marrow Biopsy done 3/31/10 Patient Bone Marrow Biopsy done 3/31/10

24. 10-2949 BM A.B. 56/Male

25. Scanner 4x

26. Low Power Objective, 10x

27. High Power Objective 40x

29. Problem: Erythrocytosis & Thrombocytosis Bone Marrow, Core Biopsy and Aspirate Smears (3/31/2010) Normocellular bone marrow (40-50%) with orderly trilineage hematopoiesis.

30. Problem: Erythrocytosis & Thrombocytosis WHO Classification of Chronic Myeloproliferative Disorders (Neoplasm) Chronic Myelogenous Leukemia Chronic Idiopathic Myelofibrosis Essential Thrombocytosis Polycythemia Vera Essential Thrombocytosis Elevated platelet count hemorrhagic and thrombotic tendencies mild neutrophilic leukocytosis normal or elevated LAP score Bone marrow biopsy reveals megakaryocyte hyperplasia and hypertrophy with increase in marrow cellularity Essential Thrombocytosis Elevated platelet count hemorrhagic and thrombotic tendencies mild neutrophilic leukocytosis normal or elevated LAP score Bone marrow biopsy reveals megakaryocyte hyperplasia and hypertrophy with increase in marrow cellularity Patient Platelet count not consistently elevated elevated LAP score Normal bone marrow biopsy Patient Platelet count not consistently elevated elevated LAP score Normal bone marrow biopsy

31. Problem: Erythrocytosis & Thrombocytosis Polycythemia Vera Study Group (PVSG) increased red blood cell mass (red cell volume > 36ml/kg) or increased hgb or hct Disorders causing secondary erythrocytosis are absent. PVSG criteria: two basic criteria plus 2 of the ff.: Platelet count >400,000/microL White blood cell count >12,000/microL LAP score greater than 100 Presence of a JAK2 gene mutation Bone marrow biopsy showing hypercellularity with prominent erythroid, granulocytic, and megakaryocytic proliferation

32. Problem: Erythrocytosis & Thrombocytosis Polycythemia Vera Study Group (PVSG) increased red blood cell mass (red cell volume > 36ml/kg) or increased hgb or hct Disorders causing secondary erythrocytosis are absent. PVSG criteria: two basic criteria plus 2 of the ff.: Platelet count >400,000/microL White blood cell count >12,000/microL LAP score greater than 100 Presence of a JAK2 gene mutation Bone marrow biopsy showing hypercellularity with prominent erythroid, granulocytic, and megakaryocytic proliferation

33. Complete Blood Count

34. Problem: Microcytic and Hypochromic RBC

35. Hgb Electrophoresis

36. Problem: Microcytic and Hypochromic RBC Hemoglobin Electrophoresis (Feb 2010): Marked elevation of Hemoglobin A2. Suggestive of Beta-thalassemia intermedia.

37. Problem: Microcytic and Hypochromic RBC Genetic Studies (May 6, 2010): No apparent chromosomal abnormality Thalassemia Screening in the Philippines using High Performance Liquid Chromatography (HPLC) (July 9, 2010): HPLC tracing is indicative of beta-thalassemia, intermedia

38. Polycythemia Vera Most common of the myeloproliferative disorders Incidence: 2 per 100,000 persons Etiology: Unknown  nonrandom chromosome abnormalities such as 20q, trisomy 8, and 9p  JAK2 V617F mutation causing constitutive activation of the kinase

39. Janus Kinase2-gene (JAK2) Janus Kinase 2 (JAK2) has tyrosine kinase activity and is involved in signal transduction from EPOR (erythropoietin receptor) to nucleus for gene expression

40. Polycythemia Vera: Clinical Features Splenomegaly Elevated Hgb and Hct Neurologic symptoms: vertigo, tinnitus, headache, visual disturbances, TIAs Systolic hypertension Venous or arterial thrombosis Intraabdominal venous thrombosis Digital ischemia, easy bruising, epistaxis, acid peptic disease or GI hemorrhage

41. Polycythemia Vera: Diagnosis Erythrocytosis, leukocytosis, thrombocytosis Increased leukocyte alkaline phosphatase (LAP) score Hyperuricemia Elevated Vit B12 or B12 binding capacity BMA: no specific diagnostic information No specific cytogenetic abnormality

42. Polycythemia Vera: Complications Increase in blood viscosity Increased turnover of red cells, leukocytes and platelets with the attendant increases in uric acid and cytokine production Spleenic infarction Increased incidence of acute nonlymphocytic leukemia erythromelalgia

43. Polycythemia Vera: Treatment Phlebotomy or bloodletting has been the mainstay of therapy. Elevated platelet counts may be exacerbated by phlebotomy, thus is an indication to use myelosuppressive agents to avoid thrombotic or hemorrhagic complications.

44. Polycythemia Vera: Treatment Hydroxyurea has been the mainstay therapy after the PVSG results indicated it as an effective agent for myelosuppression. The role of HU in leukemic transformation is not clear, but several nonrandomized studies have supported or refuted a significant rise in leukemic conversion with long term use of HU in persons with polycythemia vera (from 2.1% to 10%). Besa, Emmanuel, M.D., and Woermann, Ulrich, M.D. Polycythemia Vera: Treatment and Medication. January 23, 2009.

45. Thalassemia Syndromes Inherited disorders of α or β globin biosynthesis, diminished production of Hgb tetramers Unbalanced chain accumulation Massive bone marrow expansion deranges growth and development (“chipmunk” facies) Chronic transfusion leads to iron overload

46. Thalassemia Syndromes α Thalassemia β Thalassemia

47. β Thalassemia Major: either no effective production or severely limited production of beta globin. β Thalassemia Minor: heterozygotes who have inherited a single gene leading to reduced beta globin production. β Thalassemia Intermedia: disease of intermediate severity, such as those who are compound heterozygotes of two thalassemic variants.

48. β Thalassemia Intermedia Malaise, pallor, easy fatigability, splenomegaly CBC reveal anemia with marked hypochromasia and microcytosis Accepted Hgb: 6-7 g/dL without blood transfusions. Treatment: close monitoring and observation. Indications for blood transfusions: intercurrent infections, hypersplenism, or other illnesses.

49. β Thalassemia Minor and Newly Diagnosed Polycythemia Rubra Vera in a 71- year old Woman Jason Preston Thomas, M.D. Hospital Physician April 2001 β Thalassemia Minor and polycythemia rubra vera (PRV) are hematologic disorders that give opposite results and the 2 disease entities occurring simultaneously has only been reported ONCE. Due to the low-grade hemolysis resulting from precipitation of impaired alpha globin chains in association with β Thalassemia Minor, the often substantial elevations in Hgb and Hct seen in PRV were probably blunted. The low grade anemia of β Thalassemia Minor is not evident because of the overproduction of erythrocytes.

50. Final Diagnosis Myeloproliferative Disease probably Polycythemia Vera Beta Thalassemia Intermedia Hypertensive Cardiovascular Disease Dyslipidemia Hyperuricemia Chronic Kidney Disease probably secondary to Hypertensive Nephrosclerosis

51. Complete Blood Count 10/2/10

52. Conclusion Beta Thalassemia and PRV are 2 indirectly opposing processes and its occurrence in a patient is rare. For the long term, chemotherapy could be considered if the patient develops a blood clot or requires phlebotomies too frequently. Median survival of PRV in the absence of therapy extended to at least 10-20 years. Thrombotic complications are the main cause of morbidity and mortality, hence close monitoring and observation with repeat CBC should be done every 2 months.

53. On Follow up Patient is doing well, asymptomatic. Has been having regular follow up every 2 months with repeat CBC, and undergoes phlebotomy depending on CBC results.

54. THANK YOU AND GOOD DAY!!!

55. Problem: Erythrocytosis & Thrombocytosis Polycythemia Vera Study Group (PVSG) increased red blood cell mass (red cell volume > 36 ml/kg) or increased hgb or elevated hct Disorders causing secondary erythrocytosis are absent. WHO criteria: two basic criteria plus 2 of the ff.: Platelet count >400,000/microL White blood cell count >12,000/microL Low serum EPO levels Presence of a JAK2 mutation Bone marrow biopsy showing hypercellularity with prominent erythroid, granulocytic, and megakaryocytic proliferation Patient elevated blood volume (5,367.10 ml) elevated red blood cell volume (3,273.93 ml) Hypertension nonsmoker platelet count > 400,000 (459,0000) positive for JAK2 gene mutation high LAP score (70% sensitivity) hyperuricemia Patient elevated blood volume (5,367.10 ml) elevated red blood cell volume (3,273.93 ml) Hypertension nonsmoker platelet count > 400,000 (459,0000) positive for JAK2 gene mutation high LAP score (70% sensitivity) hyperuricemia