Polycythemia due to COPD and Smoking

Author: V. Dimov, M.D., Section of Hospital Medicine, Cleveland Clinic

Dr. Damodaran presents the case (audio recording is currently unavailable).

A 54-year-old female is admitted to the hospital with chief complain of SOB for 2 days. She also complains of cough with wheezing, and denies chest pain, fever or chills.

PMH:
COPD/asthma, HTN, hypothyroidism

Medications:
Aspirin, Lasix, Maxzide, albuterol, Synthroid

Allergies:
PCN

SH:
Smoker, denies alcohol or illicit drug use

Physical examination:
VS 36.3-22-60-118/86
Chest: decreased air movement (B) with wheezing
CVS: Clear S1S2
Abdomen: Soft, NT

Laboratory results:
ABG on 4 L/min: pH 7.39, pCO2 53, pO2 68, SpO2 89%

CXR: Scoliosis, cardiomegaly, atelectasis, and pleural scarring
EKG: NSR

What happened?
Patient was given breathing treatments with albuterol and Atrovent, terbutaline 0.3 mg SQ x 2, Solu-Medrol 60 mg IV and magnesium 2 g in 100 ml of saline over one hour.

After this treatment, the patient was saturating at 78% to 80% on RA. She was admitted for treatment of COPD exacerbation.

CBC showed polycythemia: Hgb 20 mg/dL, Hct 60


CBC in polycythemia

What tests would you order in the work-up of polycythemia?
Check SpO2, ABG, epoetin level, B12 and alkaline phosphatase


SpO2 and ABG in secondary polycythemia


CMP, B12; epoetin level is very high

Final diagnosis:
Polycythemia secondary to hypoxemia due to COPD

What happened next?
The patient reported improvement in SOB with COPD therapy. Hematocrit decreased with hydration, and she was discharged home with home O2 and follow-up with her PCP in 2 weeks.


COPD treatment, note the nicotine patch

What did we learn from this case?
Polycythemia can be one of two types: primary (a true bone marrow disorder) and secondary.

Secondary polycythemia is much more common and is due to heavy smoking (elevated carboxyhemoglobin), COPD or dehydration. Our patient's condition is due to smoking and low SpO2 due to COPD.

Polycythemia vera is diagnosed by using the Polycythemia Vera Study Group major criteria: elevated red blood cell mass (not a practical test, rarely done), SpO2 > 92%, and palpable splenomegaly (3 major criteria).

Polycythemia rubra vera (PRV) is an autonomous RBC proliferation (not dependent on erythropoetin), and epoetin level is low or normal. Low epoetin level has 70% sensitivity and 90% specificity for polycythemia vera.

Other lab findings in PRV (minor criteria):
Platelets > 400
WBC> 12
High leukocyte alk phos (LAP)> 100, DDx with CMP in which LAP is low
High B12> 900
Low MCV

PRV is a part of the myeloproliferative disorders, remembered by the mnemonic MEPC:
Myelofibrosis
Essential Thrombocythemia
PRV
CML

References:
Polycythemia Vera - AFP 05/04
Polycythemia Vera (Primary Polycythemia; Vaquez' Disease) - Merck Manual
Polycythemia Vera - eMedicine

Related:
Polycythema vera. Pulmonary Roundtable, March 13, 2006.
Chronic Obstructive Pulmonary Disease (COPD). AllergyCases.org.
Desperate to Cry, Desperate Not To. NYTimes.

Published: 05/11/2005
Updated: 04/14/2008