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Insight

Soumya Sayujya: A Routine Lab, An Incidental Finding, And a Lesson I Won’t Forget

Soumya Sayujya/LinkedIn

Oct 19, 2025, 06:11

Soumya Sayujya: A Routine Lab, An Incidental Finding, And a Lesson I Won’t Forget

Soumya Sayujya, Internal Medicine Physician, East Point College of Medical Sciences and Research Centre, shared on LinkedIn:

”A Routine Lab. An Incidental Finding. And a Lesson I Won’t Forget.

A 53-year-old man came in for a simple arm cut while removing drywall.
His lab showed: Hb 20 g/dL, Hct 59%.
At first, I thought it was a lab error. My senior said, “Let’s think this through.”

Step 1: Relative vs Absolute Erythrocytosis

Elevated hematocrit can be:
• Relative: from dehydration or diuretics
• Absolute: due to a primary marrow disorder (Polycythemia Vera) or secondary causes (hypoxia, renal disease, tumors, drugs).

He wasn’t dehydrated, didn’t take medications, had normal BMI, SpO₂ 95%, but had a palpable spleen.

Step 2: The CBC Clues
• WBC: 15,400 (normal diff)
• Platelets: 445,000

Erythrocytosis + leukocytosis + thrombocytosis + splenomegaly → Polycythemia Vera (PV) — a clonal myeloproliferative disorder where the marrow overproduces all three lines.

Step 3: JAK2 Mutation

95% of PV cases have the JAK2 V617F mutation,
causing constitutive tyrosine kinase activation.
It’s also seen (less often) in essential thrombocytosis and primary myelofibrosis.

Step 4: Work-up
• RBC mass → confirms absolute erythrocytosis
• EPO levels → low in PV, high in secondary causes
• ABG/PFTs → for hypoxia
• Renal USG → for EPO-secreting tumors

All findings pointed to a primary marrow process.

Step 5: Symptoms and Risks

Pruritus after hot showers, headaches, dizziness, splenic fullness — classic PV.
The danger lies in thrombosis — TIAs, strokes, visual symptoms, gout.

Step 6: Management

Risk stratification:
• Low risk: <60 yrs, no thrombosis
• High risk: ≥60 or past thrombosis

He was low risk → Phlebotomy (to reduce viscosity) + low-dose aspirin (to prevent clots).
Hydroxyurea and Ruxolitinib are for high-risk or refractory cases.
Warfarin isn’t used prophylactically.

Reflection

A trivial injury led to a myeloproliferative neoplasm with a molecular signature.
From Hct 59% → splenomegaly → JAK2 mutation → PV,
every clue unfolded like a clinical mystery.

Sometimes, the most important diagnoses hide in “routine” labs.
Because in medicine, every number tells a story — if you take the time to listen.”

Soumya Sayujya: A Routine Lab, An Incidental Finding, And a Lesson I Won’t Forget

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