Gangadharamurthy Dakshin, Shih Henry
Tufts University/Brockton Hospital, Brockton, Massachusetts, USA.
BMJ Case Rep. 2013 Jul 8;2013:bcr2012008214. doi: 10.1136/bcr-2012-008214.
A man in his late 60s presented with symptoms for a few months of itching and head ache after shower. Physical examination was unremarkable except for ruddy complexion and splenomegaly. Complete blood count showed haemoglobin of 18.1 g/dL and haematocrit of 56.6%. To rule out secondary causes of erythrocytosis, such as congenital heart disease with a right to left shunt, a transthoracic echocardiogram was performed, which showed normal left ventricular function with an apical area of dyskinesis and a large left ventricular apical thrombus measuring 3.0 cm×2.0 cm. Further laboratory investigations showed low erythropoietin level and Jak V617F mutation consistent with the diagnosis of polycythemia vera. He was treated with aspirin, enoxaparin, phlebotomy and hydroxyurea with no reported complications during the stay.
一名60多岁的男性在几个月来出现了淋浴后瘙痒和头痛的症状。体格检查除面色红润和脾肿大外无异常。全血细胞计数显示血红蛋白为18.1 g/dL,血细胞比容为56.6%。为排除红细胞增多症的继发原因,如伴有右向左分流的先天性心脏病,进行了经胸超声心动图检查,结果显示左心室功能正常,但心尖部有运动障碍区域以及一个大小为3.0 cm×2.0 cm的巨大左心室心尖血栓。进一步的实验室检查显示促红细胞生成素水平低以及存在Jak V617F突变,符合真性红细胞增多症的诊断。他接受了阿司匹林、依诺肝素、放血疗法和羟基脲治疗,住院期间未报告有并发症。