Relative Polycythemia -- Am I wrong?

[Azete]

M3 in the middle of ER rotation. 26 y/o male came in via EMS after syncope during a run. EKG shows only sinus tach w/ HR 115, BP 138/89, O2 99%, afebrile. CBC normal except hgb 19.3, hct 52%. Attending asks what I think and I suggest possible polycythemia with primary care and/or hematology follow-up. He immediately dismisses this and says "it's only dehydration, stop looking for zebras."

Now, I definitely agree that dehydration is pretty obvious, but could relative polycythemia via dehydration alone really raise hgb that high? I was under the impression that 17-18 would be dehydration, whereas >19 is an "oh ****" number. Someone help me be less stupid.

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[Cawolf]

UTD suggests that all males with a hgb > 18.5 likely have increased red cell mass, as opposed to reduced plasma volume. I would be curious about the physical exam, PV symptoms, family hx, and smoking hx though.

So I don't think you are crazy!

 

[Redpancreas]

M3 in the middle of ER rotation. 26 y/o male came in via EMS after syncope during a run. EKG shows only sinus tach w/ HR 115, BP 138/89, O2 99%, afebrile. CBC normal except hgb 19.3, hct 52%. Attending asks what I think and I suggest possible polycythemia with primary care and/or hematology follow-up. He immediately dismisses this and says "it's only dehydration, stop looking for zebras."

Now, I definitely agree that dehydration is pretty obvious, but could relative polycythemia via dehydration alone really raise hgb that high? I was under the impression that 17-18 would be dehydration, whereas >19 is an "oh ****" number. Someone help me be less stupid.

I'm a 25 yo male and an avid runner with an isolated elevated Hct of 18.5ish and it's been like that since I've been about 12.

EDIT: I don't use steroids.

 

[Crayola227]

steroids

 

[Azete]

UTD suggests that all males with a hgb > 18.5 likely have increased red cell mass, as opposed to reduced plasma volume. I would be curious about the physical exam, PV symptoms, family hx, and smoking hx though.

So I don't think you are crazy!

PE mostly normal except for sunken eyes. No other sx other than a history of anxiety w/ tachycardia (echo 5 yrs ago was normal). Family hx of ischemic heart disease. Doesn't smoke. BMI ~20; highly doubt steroid use.

 

[Raryn]

M3 in the middle of ER rotation. 26 y/o male came in via EMS after syncope during a run. EKG shows only sinus tach w/ HR 115, BP 138/89, O2 99%, afebrile. CBC normal except hgb 19.3, hct 52%. Attending asks what I think and I suggest possible polycythemia with primary care and/or hematology follow-up. He immediately dismisses this and says "it's only dehydration, stop looking for zebras."

Now, I definitely agree that dehydration is pretty obvious, but could relative polycythemia via dehydration alone really raise hgb that high? I was under the impression that 17-18 would be dehydration, whereas >19 is an "oh ****" number. Someone help me be less stupid.

Whatever is going on is almost certainly not an emergency, so your attending was right. A PCP followup with a repeat lab would be pretty reasonable, so you're right there. I'd rehydrate him and tell him to f/u with a PCP, both because it's the right thing to do and to cover my own ass.

 

[HomeSkool]

UTD suggests that all males with a hgb > 18.5 likely have increased red cell mass, as opposed to reduced plasma volume.

Saying "all" can get you burned, particularly when talking about a patient with profound dehydration. Be careful with absolutes.

Now, I definitely agree that dehydration is pretty obvious, but could relative polycythemia via dehydration alone really raise hgb that high? I was under the impression that 17-18 would be dehydration, whereas >19 is an "oh ****" number.

Instead of fixating on that hemoglobin level in isolation, consider the complete clinical picture:

- Young male, healthy enough to go for a run. Hemoglobin Concentration (Hb): Reference Range, Interpretation, Collection and Panels gives a normal hemoglobin range of 14-17.5.
- Patient presented with multiple signs of dehydration: tachycardia, sunken eyes, elevated h/h, historical factors (i.e., had been out running)
- The dehydration was profound: the patient got so dehydrated that he stopped perfusing his brain and syncopized (the subsequent catecholamine surge is probably why he wasn't hypotensive)
- Assuming his other red cell indices were WNL, his CBC wouldn't suggest that he was kicking out RBCs at an increased rate

Treat this like a puzzle and put the pieces together. If it walks like a duck and talks like a duck... And this whole thing walks and talks a lot like profound dehydration.

So @Raryn is absolutely right: the patient's most pressing immediate need is volume resuscitation. More sinister etiologies for his erythrocytosis (such as primary polycythemia) should only be considered if his h/h remain significantly elevated on follow-up labs with his PCP. (But I doubt a PCP would even get follow-up labs. They'd probably do a history and physical, and tell the guy to follow up if he had any further symptoms.)

Someone help me be less stupid.

You're not stupid, just inexperienced. Getting the necessary experience is what med school and residency are for.

But polycythemia really is a zebra. 😉

 

[Raryn]

So @Raryn is absolutely correct: the patient's most pressing immediate need is volume resuscitation. More sinister etiologies for his erythrocytosis (such as primary polycythemia) should only be considered if his h/h remain significantly elevated on follow-up labs with his PCP. (But I doubt a PCP would even get follow-up labs. They'd probably do a history and physical, and tell the guy to follow up if he had any further symptoms.)

A repeat CBC doesn't cost very much and is an easy test to get. Most PCPs would do it. But I agree there's probably some that wouldn't.

 

[HomeSkool]

A repeat CBC doesn't cost very much and is an easy test to get. Most PCPs would do it. But I agree there's probably some that wouldn't.

Here's how the situation would translate to my world:

- This would have to be an emergency case because I'd never do an elective case on someone that profoundly dehydrated
- If the dehydration were from bleeding, I'd start giving product right away; if not, I'd start with crystalloid
- I'd have an a-line to monitor an emergency patient whose dehydration had caused recent syncope
- I'd get the hemoglobin off blood gases intermittently throughout the case (which I'd be getting to track the improvement of his jacked-up lytes and base deficit)

 

[mehc012]

Here's how the situation would translate to my world:

- This would have to be an emergency case because I'd never do an elective case on someone that profoundly dehydrated
- If the dehydration were from bleeding, I'd start giving product right away; if not, I'd start with crystalloid
- I'd have an a-line to monitor an emergency patient whose dehydration had caused recent syncope
- I'd get the hemoglobin off blood gases intermittently throughout the case (which I'd be getting to track the improvement of his jacked-up lytes and base deficit)

I'm sorry, what makes this an emergency case? Or what would? I'm having a hard time seeing what would merit an a-line for a guy who passed out while running, or where the jacked up lytes and base deficit came from (or why a blood gas to begin with).

Legitimately curious...I used to hate the water where I lived and we never had sugary drinks in the house, so I would routinely pass out in the summers just from dehydration, and we never considered it a doctor-worthy thing. Is it usually?

 

[HomeSkool]

I'm sorry, what makes this an emergency case? Or what would? I'm having a hard time seeing what would merit an a-line for a guy who passed out while running, or where the jacked up lytes and base deficit came from (or why a blood gas to begin with).

Legitimately curious...I used to hate the water where I lived and we never had sugary drinks in the house, so I would routinely pass out in the summers just from dehydration, and we never considered it a doctor-worthy thing. Is it usually?

Just a hypothetical. But let's suppose the guy was unlucky enough to get syncope from dehydration at the same time a formerly reducible hernia became strangulated. That guy would get emergency surgery and an a-line.

But again, just a hypothetical. The point is that I'd have to be reeeeeeally convinced that the guy needed immediate surgery; otherwise my answer to my surgeons would be "lolz nice try, come back when he's optimized."

 

[HomeSkool]

we never considered it a doctor-worthy thing. Is it usually?

Very much so. People die from that sort of thing.

 

[Raryn]

I'm sorry, what makes this an emergency case? Or what would? I'm having a hard time seeing what would merit an a-line for a guy who passed out while running, or where the jacked up lytes and base deficit came from (or why a blood gas to begin with).

Legitimately curious...I used to hate the water where I lived and we never had sugary drinks in the house, so I would routinely pass out in the summers just from dehydration, and we never considered it a doctor-worthy thing. Is it usually?

He's saying that the only time he, as an anesthesiologist, would encounter such a question would be in some kind of bizarre emergency case. Not entirely sure why that point is relevant though.

 

[mehc012]

Just a hypothetical. But let's suppose the guy was unlucky enough to get syncope from dehydration at the same time a formerly reducible hernia became strangulated. That guy would get emergency surgery and an a-line.

But again, just a hypothetical. The point is that I'd have to be reeeeeeally convinced that the guy needed immediate surgery; otherwise my answer to my surgeons would be "lolz nice try, come back when he's optimized."

Ahh, so the emergency you were referencing was not actually related to the dehydration.

 

[HomeSkool]

He's saying that the only time he, as an anesthesiologist, would encounter such a question would be in some kind of bizarre emergency case. Not entirely sure why that point is relevant though.

Just an amusing aside.

Ahh, so the emergency you were referencing was not actually related to the dehydration.

Yep.

 

[boogaaloo]

I'm a 25 yo male and an avid runner with an isolated elevated Hct of 18.5ish and it's been like that since I've been about 12.

EDIT: I don't use steroids.

How are you still living!

 

[Redpancreas]

How are you still living!

16-17. Not that high, nvm

 

[hallowmann]

16-17. Not that high, nvm

So it was all LIES! I trusted you Syncrohnize, I trusted you...

Seriously though, the first thing I thought of with your post steroids, glad you clarified.

 

[mayonnaise_clinic]

I'm a 25 yo male and an avid runner with an isolated elevated Hct of 18.5ish and it's been like that since I've been about 12.

EDIT: I don't use steroids.

Hi sir. I know this is a very old thread and it is highly unlikely I won't get answer but I wanted ask you a question.
I am experiencing exactly the same thing (though a bit lower in Hgb level).
I am male and my Hgb level has been between 17.4-18.5. (depending on the hydration status)
I went through, extensive work-up including but not limited to JAK2 testing, Hematology panel (JAK2, CALR, JAK2 EXON 12...etc and many other common genes), BM biopsy, cytology, EPO level, familial erythrocytosis panel (EPOR, HIF, HBA, HBB, etc), P50 study, echocardiography, abdomen CT, hormone test (testosterone, GH, IGF...), Brain MR and PFT.
And everything was within normal range. (All the gene tests were all negative multiple times)
I am overweight but not morbidly obese and I don't smoke. I work out regularly (though not enough!)
My oncologist say he is almost certain that it is of benign nature and shouldn't be worried too much. (He thinks I am just 99% percentile regarding Hgb level)
I was just wondering what your oncologist said to you...
Hope you get the notification and respond me back.

Sorry for my lousy english. (I am IMG and still working on my English)

Thank you

 

[catnip12]

Hi sir. I know this is a very old thread and it is highly unlikely I won't get answer but I wanted ask you a question.
I am experiencing exactly the same thing (though a bit lower in Hgb level).
I am male and my Hgb level has been between 17.4-18.5. (depending on the hydration status)
I went through, extensive work-up including but not limited to JAK2 testing, Hematology panel (JAK2, CALR, JAK2 EXON 12...etc and many other common genes), BM biopsy, cytology, EPO level, familial erythrocytosis panel (EPOR, HIF, HBA, HBB, etc), P50 study, echocardiography, abdomen CT, hormone test (testosterone, GH, IGF...), Brain MR and PFT.
And everything was within normal range. (All the gene tests were all negative multiple times)
I am overweight but not morbidly obese and I don't smoke. I work out regularly (though not enough!)
My oncologist say he is almost certain that it is of benign nature and shouldn't be worried too much. (He thinks I am just 99% percentile regarding Hgb level)
I was just wondering what your oncologist said to you...
Hope you get the notification and respond me back.

Sorry for my lousy english. (I am IMG and still working on my English)

Thank you

SDN is not meant for Medical advice so you won’t find the help you need here. It’ll be more beneficial to contact a local physician to address your health concerns.

Good luck

 

[Matthew9Thirtyfive]

This forum isn’t for medical advice, and this thread is over two years old.